SAN DIEGO UNIFIED SCHOOL DISTRICT Preschool-Grade 12 ENROLLMENT FORM 2017-18

Complete Sections I-III and sign page 2. Section IV must be completed by office staff. Please print legibly using black or blue pen. For full directions, please refer to Directions for Completing the PreK-12 Enrollment Form available at https://www.sandiegounified.org/enrollment-forms.

OFFICE ONLY 1.Student District ID:

OFFICE ONLY 2. Student State ID (SSID):

I. STUDENT INFORMATION

3. Last name (LEGAL NAME ONLY) First Middle Suffix (Jr, II, III)

4. Preferred/Actual Name: 5. Former legal name(s) (optional): 6. Birthdate: 7. Social Security Number (optional):

/ / -- -- 8. Gender Female Male

9. Is student Hispanic or

Latino? Yes No

10. Race: (check all boxes that apply)

American Indian or Alaskan Native Black or African American Filipino White

Asian/ Indochinese Asian Indian Cambodian Chinese Hmong Japanese Korean Laotian Vietnamese Other Asian

Pacific Islander Guamanian Hawaiian Samoan Tahitian Other Pacific Islander

11. Release of Information: Directory-type information may be shared with individuals and organizations authorized to receive this type of information unless it is prohibited by the parent/guardian. See the district’s Facts for Parents for the individuals and organizations, and the student information that may be

released. If you do not want the information shared, you must select “Opt Out.” Opt Out

12. Student email address (optional):

13. Household address: City, State: ZIP Code:

14. Home phone:

( ) 15. Mailing address (if different from household): City, State: ZIP Code:

16. City, State, Country of birth:

17. First enrolled in a CA school (K-12): Date: / /

18. First enrolled in a US school (K-12): Date: / /

19. Current Caregiver (check one): Parent/legal guardian Other adult (not legal guardian, requires Caregiver Affidavit)

20a. Foster Living Situation:

Check if applicable: Family Home (FFH) Group Home (FGH) (FFA) Formal Kinship Care (including NREFM)

20b. Homeless Living Situation (temporary residence due to financial hardship):

Check if applicable: Living with someone/Doubling up Unaccompanied Youth Hotel/motel Sheltered Unsheltered Runaway Youth

21. Other Living Situation: International Exchange Residential facility Hospital (not state hospital) ___________________________

22. Complete and include siblings who are currently in PreK–Grade 12 in San Diego Unified (only if applicable).

Sibling 1 Full name: Grade: School name:

Sibling 2 Full name: Grade: School name:

Sibling 3 Full name: Grade: School name:

II. CONTACT INFORMATION Provide at least three contacts—if additional space is needed use “Notes” in Section IV on back of form.

23. Parent/Guardian/Contact 24. Parent/Guardian/Contact 25. EMERGENCY CONTACTS (OTHER THAN PARENTS)

Full name Full name:

Relationship to student

Lives with student?

Yes No If no, provide address here:

___________________________

___________________________

Yes No If no, provide address here:

____________________________

____________________________

Relationship to student:

Home phone ( )

Work phone ( )

Home phone ( ) ( ) Cell Phone ( )

Work phone ( ) ( ) Interpreter required OK to release student

Cell phone ( ) ( )

Email address Full name:

Employer

Military (check all that apply): Active Duty DOD Employee Active Duty DOD Employee Relationship to student:

National Guard Reserves National Guard Reserves

Primary language

Education level (select one)

Not a High School Graduate High School Graduate Some College/AA Degree College Graduate Graduate School/Post-Graduate Decline to state

Not a High School Graduate High School Graduate Some College/AA Degree College Graduate Graduate School/Post-Graduate Decline to state

Home phone ( )

Work phone ( )

Cell phone ( )

Additional information Interpreter required Access to student info online Report Cards & Progress Reports provided

Report card Progress report Interpreter required Access to student info online

Interpreter required OK to release student

SIGNATURE REQUIRED ON REVERSE

OFFIC

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____________________________________________ G

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___________________________ R

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III. QUESTIONS FOR PARENT/GUARDIAN

The following questions provide important information for the school staff. Parents must answer the following questions. Check “Yes” or “No” for each question where appropriate. Questions 30 & 32 require that you check “Opt Out” or leave blank if you agree to your student’s participation.

26a. Has your student ever received

Special Education services?

26b. Does your student have a 504?

Yes No

Yes No

27. Has one of the parents/guardians engaged in migrant work (moved and worked seasonally in jobs related to agriculture, lumber or fishery) in the past three years?

Yes No

28. Name, city, and state/country of last school attended:

__________________________________________________________

__________________________________________________________

__________________________________________________________

Last grade level completed: ________

29. (For students born outside the U.S., see #18) Was this student born in a foreign country to diplomatic, military personnel or other U.S. citizen, and granted U.S. citizenship?

Yes No

30. (For students in Grades 7, 9, & 11) Opt Out The district would Like your student to participate in the California Healthy Kids Survey (CHKS). The survey is anonymous and confidential. If you do not want your student to participate, you must select “Opt Out”.

31. (High school students only) Has your student ever played interscholastic athletics?

Yes No

32. (High school students only) Federal law requires release of student information to military recruiters. If you do NOT want this information released for your student, you must select “Opt Out”. http://www2.ed.gov/policy/gen/guid/fpco/hottopics/ht-10-09-02a.html

Opt Out

33. (High school students only) Parents may authorize their student’s school to release educational information including, but not limited to: a. Transcripts, Letters of Recommendation, Financial Aid Forms, GPA Verification Forms, School Reports, and Class Ranking Status b. Disciplinary Records

By checking “Yes” I give permission to State/Federal Financial Aid Programs/Scholarship Programs/Private Schools/University/College personnel and their authorized agents to access my student’s educational records.

Yes

Yes

The information provided in Sections I-III is true to the best of my knowledge.

Parent/Guardian/Contact signature (required) Date

IV. DISTRICT ADMINISTRATIVE INFORMATION – FOR OFFICE USE ONLY

34. Address verification document:

36. Neighborhood School: ______________________________

38. District of residence: ___________________________

Interdistrict attendance permit InterSELPA agreement

35. Date address verified: / /

37. Birth verification documents:

Birth certificate Affidavit Church records Passport I-94

School records Unverified

39. Boundary exception for non-resident student __

ENTRY INFORMATION

40. Previously enrolled in San Diego Unified? Yes* No

*If Yes: Last year enrolled_______________ School______________________________________ Grade___________

41. Entry date: ______ / ______ / _____

42. Entry reason (check one):

Enter from within San Diego Unified Enter from Out of District Initial Enrollment-Preschool Enter from Out of State

Initial Enrollment TK-12 Preschool Enroll-Not Initial Enter from Charter School within San Diego Unified

43. For students new to San Diego Unified entering from

within California:

Student State ID (SSID) (if known): ______________________

Previous CA district: ___________________________________

Previous CA school name: ______________________________

44. For students new to San Diego Unified entering from outside of California:

Previous school name: _________________________________________________

City, State/Country: ___________________________________________________

EXIT INFORMATION

45. Exit date: ______ / ______ / ______ 46. Exit reason (check one):

47a. Immunization status: Grades PK-12: transferred within San Diego Unified transferred out of San Diego Unified

47b. Dental Exam (K only)? Yes No withdrew No Show-Enrollment Dropped

Complete Incomplete Exempt Other: _________________________________________________________

LEGAL BINDINGS/NOTES/ADDITIONAL INFORMATION

SAN DIEGO UNIFIED SCHOOL DISTRICT PreK–Grade 12 ENROLLMENT FORM 2017-18 (rev 3.13.2017)

CALIFORNIA DEPARTMENT OF EDUCATION Form CD 9600A, (Rev. 01/04)

Child Care Data Collection

Privacy Notice and Consent Form

The United States Department of Health and Human Services (HHS) is gathering information about

families who receive child care assistance. The information will be reported to the California

Department of Education (CDE) and then to HHS. The information will be used for research on the

status of child care in the United States and will provide valuable data to persons developing child care

programs and policies at the state, local, and national levels.

All the information HHS receives about your family and other families will be summed up and reported

to Congress every two years. No person or family will be individually identified in reports made to

Congress, the Legislature, other governmental agencies, or the public.

To ensure that children and families receiving child care services are counted only once, HHS and

CDE are requesting the Social Security Number of the head of the family unit receiving child care

assistance. If you do not wish to give your Social Security Number for this purpose, you may still

receive child care assistance. Social Security Numbers will help CDE meet HHS reporting requests

and state requirements for program statistics. Authority to ask for your Social Security Number for this

purpose is stated in Section 98.71(a)(13) of Title 45 of the Code of Federal Regulations, Education

Code Section 8261.5, and Section 18070 of Title 5 of the California Code of Regulations. Your

decision to provide your Social Security Number is voluntary. I have been informed of the way my Social Security Number will be used. I understand that if I do not wish to give my number, I can still receive child care assistance.

YES, my Social Security Number may be used: _______-_____-_______

NO, I do not wish to give my Social Security Number for this purpose. ______________________________________ ____________________ Signature of the Head of Household Date ______________________________________ Type or Print Name

You have the right to access records containing your personal information. For information about this system of records, contact the California Department of Education, Child Development Division, 1430 N Street, Sacramento, CA 95814; telephone (916) 445-1907.

MV:DD:ma rev. 11/6/16

HEALTH SCREENING ASSESSMENT CONSENT AND ACKNOWLEDGEMENT FORM

Child’s Name: ____________________________________________ Date: _________________________________

Your child may be eligible to receive hearing, vision, blood pressure, measurements and developmental screenings

and assessment through San Diego Unified School District and/or collaborative partners. There is no cost for these

services and you will be notified of the results. These screenings and assessments will be done by trained staff at your

child’s school. If there is a need for further evaluation, you will need to sign an additional permission slip. Your

participation may be required.

# Please indicate whether you would like your child to receive the following screenings/assessments by initialing the boxes.

INITIALS

1 I want my child to have a vision screening. Vision screenings will be conducted by SDUSD and/or collaborative partners. If your child needs glasses, the glasses will be provided to your child free of charge.

2 I want my child to have a hearing screening. Hearing screenings will be provided by SDUSD and/or collaborative partners. This screening will tell you if your child has a hearing problem. A hearing problem can affect your child’s ability to learn and be successful in school.

3 I grant staff permission to perform the following health screenings on my child: Blood pressure, height and weight. These screenings will prompt follow-up treatment for abnormal findings. Follow-up treatment is given as part of the school program.

4 Developmental assessments and screenings as well as a mental health screening will be conducted by SDUSD and/or collaborative partners. These screenings/assessments will evaluate your child’s development in speech and communication, fine motor skills, gross motor skills, social and emotional skills and problem solving skills. The findings may help school personnel provide additional support for your child. I understand that developmental and mental health screenings and assessments will be conducted as required and grant permission for staff to provide social, emotional and behavioral consultation services for my child as needed.

5 I want my child to participate in the fluoride program (daily brushing with fluoride toothpaste). Regular tooth brushing helps to prevent cavities and gum disease. Good dental health contributes to positive attitudes and success in school.

6 I understand that I must provide up-to-date immunizations or have other required documentation on file prior to my child attending the program.

7 I am aware that my child is required to have a complete physical examination annually. A completed physical exam includes; vision screening, hearing screening, measurements, anemia testing, lead testing, TB risk assessment and blood pressure results. The physical exam is due within 30 days of the child’s attendance in the program.

8 I am aware that my child is required to have a complete dental examination annually. I will be responsible to ensure that all treatment and follow-up is completed. The dental exam is due within 90 days of the child’s attendance in the program.

I have read and understand the above information.

Parent’s name_______________________________ Parent’s Signature_________________________________

San Diego Unified School District uses the California Immunization Registry (CAIR) to store immunization records for many of their students. By using this system, the school can make sure that your children’s immunization records can be easily lo-cated by a school nurse or health care provider when you change schools, doc-tors, or during a disease outbreak, or natural disaster. Once the record is in CAIR, then you will be able to access it in the future through an online registration proc-ess at http://www.sandiegoimmunizationregistry.org/mraccess/login.jsp

San Diego Unified School District staff enter immunization records into the central-ized, secure, and confidential database. Please return this completed form and a copy of the individual’s immunization record to your school. For more information, visit the SDIR Website at: www.sdiz.org/CAIR-SDIR/index.html or call the SDIR Help Desk at (619) 692-5656 .

Immunization records are online!

Please complete the information below. Fill out additional form(s) if submitting more than one individual’s immunization record.

Please print clearly and include your phone number in case we need to call you!

HHSA: IZ148ES-SDUSD 03/10

Immunization records are only shared with public health, participating health care providers, schools, childcare and other authorized programs that require the review of immunization records for enrollment. Check here only if you do not want the record to be shared. Initials:

Date of Birth:

Email:

Mother’s maiden name:

STAFF INITIALS_______

Relationship to student: Parent Guardian Other [specify]

Last name: First name:

Gender: Male Female

STUDENT

Name: Street Address: City: Zip Code:

Home Telephone:

PARENT/GUARDIAN

Signature of Parent/Guardian:

Fields below will help locate the immunization record in the future:

Medical record # (optional)

DATE: ___/___/___ ENTERED in SDIR

Office use only

Attachment A

El Distrito Escolar Unificado de San Diego utiliza el Registro de Vacunas de California (CAIR) para mantener los archivos de vacunas de muchos de sus alumnos. Por medio del registro de vacunas, el personal de la escuela de su hijo puede localizar fácilmente el archivo de va-cunas cuando su hijo cambia de escuela, doctor, o durante un brote de enfermedad o de-sastre natural. Cuando el archivo de vacunas está en el CAIR, Ud. podrá verlo en el futuro después de inscribirse en el sitio del internet: http://www.sandiegoimmunizationregistry.org/mraccess/login.jsp

El personal del Distrito Escolar Unificado de San Diego registra los archivos de vacunas en el centro de datos, el cual es seguro y privado Favor de regresar esta forma con una copia del archivo de vacunas de su hijo a la escuela. Para mas información, visite el sitio de Internet de SDIR: www.sdiz.org/CAIR-SDIR/index.html o llame al SDIR al (619) 692-5656 . Favor de llenar toda la información descrita abajo. Si necesita enviar archivos de vacunas adicionales, llene los formularios adicionales.

¡Los archivos de vacunas están en el internet!

El archivo de vacunas está compartido con programas de salud pública, proveedores de salud, escuelas, guarderías y otros programas con autorización que necesitan revisar el archivo de vacunas para inscrip-ción. Marque aquí si no quiere que el archivo de vacunas sea compartido. Iniciales:

Escriba en letra molde e incluya su teléfono en caso que tengamos alguna pregunta.

Apellido: Primer nombre: Fecha de nacimiento: Sexo: masculino feminino

ESTUDIANTE

Parentesco con estudiante

Padre de familia Guardián Otro [especifica]

Nombre: Dirección: Ciudad: Código Postal:

Correo electrónico: Teléfono:

PADRE/TUTOR

HHSA: IZ148ES-SDUSD 03/10

Los datos abajo le ayudarán a localizar el archivo de vacunas en el futuro:

Apellido de soltera de la madre:

Número de archivo médico #

STAFF INITIALS_______

Firma de Padre/Tutor:

DATE: ___/___/___ ENTERED in SDIR

Office use only

EARLY CHILDHOOD EDUCATION PROGRAMS

Child’s Health History

Student’s Name: (Last) (First) (Middle) M F

Parents/Guardian Names: (Last) (First) (Last) (First)

Telephone: Student’s Date of Birth:

TO BE COMPLETED BY PARENT/GUARDIAN

Allergy: Y N Diabetes: Y N Ear problem/Hearing Defect: Y N

Allergic to: Seizure Disorder: Y N Frequent ear infections: Y N

Reaction: Heart problems: Y N Eye problem: Y N

Chicken Pox Y N Chronic disease: Y N Glasses: Y N

Rheumatic Fever Y N Special Meals: Y N Milk Intolerance Y N

Hay Fever Y N Asthma: Y N Three-Day Measles (Rubella) Y N

Mumps Y N Poliomyelitis Y N Ten-Day Measles (Rubeola) Y N

Whooping Cough Y N

Medications: Y N List:

Previous Operations/Hospitalizations: Y N Reason:

(I), (WE), the undersigned parent/guardian of , do hereby authorize employees of the San Diego

Unified School District to obtain emergency medical treatment as prescribed and deemed necessary. This authorization is given

pursuant to the provision of Section 25.8 of the Civil Code of California and is given in advance of any specific diagnosis, treatment or

hospital care being required.

Parent/Guardian Signature Date

Historial de la Salud del Niño

Nombre del alumno: (Apellido) (Nombre) (Segundo) M F

Nombres de los padres/tutor: (Apellido) (Nombre) (Apellido) (Nombre)

Teléfono: Fecha de nacimiento del alumno:

DEBE SER COMPLETADA POR EL PADRE/TUTOR

Alergia: S N Diabetes: S N

Problemas del oído/ Defecto

auditivo:

S

N

Alérgico a: Trastorno convulsivo: S N Infecciones frecuentes del oído: S N

Reacción: Problemas del corazón: S N Problemas de los ojos: S N

Varicela S N Enfermedad crónica: S N Lentes: S N

Fibre Reumática S N Comida Especial: S N Intolerancia a la leche: S N

Fibre de Heno S N Asma: S N Sarampión de diez días (Rubéola) S N

Paperas S N Poliomielitis S N Sarampión de tres días (Rubéola) S N

Tos Ferina S N

Medicamentos: S N Lista:

Operaciones/Hospitalizaciones Previas: S N Razón:

(Yo), (Nosotros), el padre/tutor infrascrito de , autorizo por medio de la presente que los empleados del

Distrito Escolar Unificado de San Diego obtengan tratamiento médico de emergencia como sea recetado y considerado necesario. Se

otorga esta autorización según lo acordado en la provisión de la Sección 25.8 del Código Civil de California, y se da antes de que se

requiera diagnosis, tratamiento u hospital específico.

Firma del padre/tutor Fecha

MV:ma 4.10.17 (CDC/Preschool)

EARLY CHILDHOOD EDUCATION PROGRAMS

PHYSICAL: TO BE COMPLETED BY HEALTH CARE PROVIDER

Student’s Name: Student’s Date of Birth:

HT: WT: B/P: TEMP: HEART RATE: RESP:

Mandatory State Requirements: Hgb Results: ____________ Date: ______________ Lead Results: ____________ Date: ___________

TB Exposure: Y N High Risk Factors: Y N If Yes, Please Indicate Factors: _____________________________________________

Chest x-ray results needed for all positive TB tests. Date: ___________________ Results: Communicable Non-Communicable

PHYSICAL EXAMINATION

WNL ABN WNL ABN

General Appearance Lungs

Head Abdomen

Eyes Vision: Genitalia, Male

Ears Hearing: Female

Nose Hips

Mouth & Pharynx Fine Motor

Dental Gross Motor

Neck Skin

Spine Neuro

Heart Speech

Glands

SEVERE ALLERGIES

Are emergency medications needed at school? Y N (If yes, answer questions below)

Type – Antihistamine: _____________________________ EpiPen: _____________________________________

Insect (stings): Y N List: __________________________________________________________________________________

Food: Y N List: __________________________________________________________________________________

Special Meal Form Required: Y N Diagnosis, if yes: _________________________________________________________________

Medication Allergies: Y N List: ________________________________________________________________________________

ASTHMA

Inhaler Needed at School: Y N Last time child used inhaler: ____________________________

Physical Activity Limitations: _________________________________________ List: _____________________________________________

PHYSICIAN’S NAME/STAMP: _______________________________________ DATE OF PHYSICAL: _____________________________

PHYSICIAN’S SIGNATURE: ___________________________________ PHONE: ______________________ TODAY’S DATE: ____________

DENTAL HEALTH FORM

SDUSD-NHA Head Start Site: ________________________________ Phone:( )________________________ Fax:( )_______________________

2:5 Dental Health Form SDUSD/NHA/PY50/07-2015 FY17/18:MV Page 1 of 1

Child’s Name:/Nombre de alumno: ____________________________________________ Date of Birth/Fecha de nacimiento: ____ / ____ /____

PID#___________________ Male/Niño Female/Niña

Parent /Guardian/Padre/Tutor:_____________________________________ Phone/Teléfono: ( ) ______________________________

- TO BE COMPLETED BY DENTAL PROFESSIONAL -

Procedures/Services Performed during visit: (Please check all that apply)

Date of Visit: _______________________

Clinical Examination Prophylaxis/Cleaning Fluoride Treatment

Oral Hygiene Instructions Treatment/restoration (list below) Fluoride Varnish

Visual Exam only Other:______________________________ In diagram below Indicate oral condition before

treatment

Missing Tooth Decayed Filled Cavities

Please list below dental treatment/restoration performed:

Tooth

# or

Letter

Surfaces Description of Service

Date Service Performed

MO

DAY

YR

NO FURTHER TREATMENT RECOMMENDED AT THIS TIME.

ADDITIONAL DENTAL NEEDS ARE REQUIRED (Please check one or more) Prophylaxis/cleaning

Fluoride Treatment

Dental Treatment/Restoration: __________________________________

Other - Please Specify:_______________________________________________________________________________________

NEXT APPOINTMENT IS SCHEDULED FOR:______________________________

UNABLE TO PROCEED WITH TREATMENT, CHILD NEEDS TO BE REFERRED TO A PEDIODONTIST.

COMMENTS:

I certify that I have completed the service(s) listed above.

Signature/

Print Name of Dentist: ______________________________________ Official Stamped Signature: ___________________________________

Date: ______________________________________________________

Address: ___________________________________________________

Phone:_________________________ Fax: _______________________

ECS STAFF USE ONLY:

`

Official clinic stamp here