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STATE PRESCHOOL PROGRAM
Dear Parents, Thank you for choosing to enroll your child in our preschool program. We are funded by the California Department of Education and regulated by Title 5 and licensed by Community Childcare Licensing Title 22 therefore, our services are provided to families who meet income guidelines. Please provide the originals of the following documents to determine eligibility. The application is a legal document and must be completed in BLUE INK (no pencil) and SIGNED, thereby attesting under penalty of perjury these documents are true and correct. Please Note: ! If you have any questions regarding this packet, call from 7:30am – 4:30pm. to !Once you complete the application PLEASE call the Office to schedule an appointment. No exceptions. !Only the parent may submit the application. Please provide any form of identification card for your child’s record. ! If your application is incomplete it will be returned to you and you will need to return for another appointment.
!
Documents to bring the day of your appointment: "! 1 . F a m i l y A d j u s t e d G r o s s M o n t h l y I n c o m e
For accurate monthly, (30 day preceding), income verification provide one of the following: ! If you receive biweekly checks you must provide 2 recent consecutive check stubs (within a month). ! If you receive weekly checks you must provide 4 recent consecutive check stubs (within a month). ! You must provide verification stating grant amount if you receive any of the following: ! Cal Works ! TANF ! AFDC ! SSI ! Disability ! Worker’s Comp ! Unemployment ! etc… ! If Self Employed, provide a combination of documents such as, a letter from the source of income, copy of the most recently signed completed tax return with a statement of current estimated income, business record, ledgers, receipts or business logs. ! If you are a Day Laborer please provide us with a log of work done for one month or pick up a form prior to your appointment.
The presence or absence of a parent shall be documented by providing any of the following documents ! Records of marriage, divorce, domestic partnership or legal separation ! Court ordered child custody arrangements ! Evidence that the parent signing the application is receiving child support payments from that person, has filed for child custody ! Rental Receipts or agreements, contracts, utility bills or other documents for the residence of the family indicating she is the responsible party. If you are a singe parent you must show proof that you are single.
"! 2 . A d d r e s s V e r i f i c a t i o n s ( 2 P r o o f s ) ! The following documents are acceptable: driver’s license, gas bill, checkbook, electricity bill, telephone bill, etc... ! Rent receipts will NOT be accepted. ! If you do not live in the Lennox School District we will provide a permit application.
"! 3 . F a m i l y S i z e Please bring one of the following documents for every child in your home:
! Birth Certificates ! Adoption documents ! Records of Foster Care ! Court orders regarding child custody ! Other reliable documentation indicating the relationship of the child to the parent!
" 4 . P h y s i c i a n ’ s r e p o r t : D o c t o r ’ s s i g n a t u r e , s t a m p e d & d a t e d ! Hearing and vision examination ! Development delays or speech concerns ! Documentation of any other concerns, i.e.: seizures, asthma, allergies, etc...
! If your child has a current ISFP or IEP provide a copy!"! 5 . C h i l d ’ s I m m u n i z a t i o n R e c o r d
Must have the following: ! 3 Polio ! 4 DTP/DtaP/Dtp ! 3 Hepatitis B ! 1 Varicella ! Tuberculin Skin Test within a year or X-Rays within 4 years (required) The following must be given on or after the first birthday:
! 1 MMR ! 1 Hib "! 6 . V o l u n t e e r i n g p a r e n t s p r o v i d e :
"TB Test (Within a year) "MMR "DTAP "FLU 7 . P r o v i d e a n y f o r m o f i d e n t i f i c a t i o n c a r d f o r p a r e n t
(310) 680-3500 !
Lennox School District
The lack of compliance with these requirements can delay
your child’s enrollment! !
License #: Buford 192006405, Moffett 192006499, Felton 197409130, Whelan 197414587, Jefferson 197417494
Title 5, Section 18086
!
LSD Board Policy #5111 & Title 22
!
LSD Board Policy 48002 Title 22 !
Title 22
!
LSD Board Policy 5141.31 Title 22
!
Title 22
!
10203 Firmona Avenue, Inglewood, CA 90304
2/2017 BMCL
Where ch i ldren Where children
play, sing, and learn!
2017-2018
INCOME CEILING TO QUALIFY FOR STATE PRESCHOOL
In order to qualify for State Preschool Part-Day services, families must be at or below 70% of the State Median Income (SMI) to enrolling a CDE/CDD-contracted program. The table below delineates the monthly and annual income ceilings by family size used to determine their eligibility for enrollment in a program contracted by the CDE/CDD. If your income is lower than the shaded column, your child qualifies for FREE preschool.
Schedule of Income Ceilings for the State Preschool Program
QUALIFY 15% (Qualify) Family Size Monthly Yearly Monthly Yearly
1 to 2 $3,283 $39,396 $3,775 $45,305 3 $3,518 $42,216 $4,046 $48,548 4 $3,908 $46,896 $4,494 $53,930 5 $4,534 $54,408 $5,214 $62,569 6 $5,159 $61,908 $5,933 $71,194 7 $5,276 $63,312 $6,067 $72,809 8 $5,394 $64,728 $6,203 $74,437 9 $5,511 $66,132 $6,338 $76,052
10 $5,628 $67,536 $6,472 $77,666 11 $5,745 $68,940 $6,607 $79,281 12 $5,863 $70,356 $6,742 $80,909
!If you do not qualify based on income in the Lennox School District State Preschool Program, consider enrolling your child in the School Readiness Center. For more information please call 310-680-8990 or 310-680-6290, (closed from 12-1pm).
BMcL 2/2017
Enrollment Dates for Children 0-5 years old If your child is going to be 3, 4 or 5 years old what
program does he/she qualify for …?
September 2, 2012 – September 1, 2014 Preschool September 2, 2012 – December 2, 2012 Transitional Kinder* December 2, 2011 – September 1, 2012 Kindergarten Children from 0-5 years old School Readiness
Date of Birth Program
* Dually enroll your child in TK and Preschool. They come to school all day.
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION
IDENTIFICATION AND EMERGENCY INFORMATION CHILD CARE CENTERS / FAMILY CHILD CARE HOMES To be completed by Parent or Authorized Representative
Child’s Information: First
Middle Last Sex Birth date School Attended Last Year
Birth City
Birth State Birth Country Hispanic: Circle one
YES NO Home Language
Street Address City State Zip Code
Telephone Number:
Father’s Information: First
Middle Last Birth date Cell Phone
( ) Work Place
Work Address City and State Zip Code Business Phone
( ) Mother’s Information: First
Middle Last Birth date Cell Phone
( ) Work Place
Work Address City and State Zip Code Business Phone
( ) Father’s Education Level (Check one) ❑ Not a High School Graduate ❑ High School Graduate ❑ Some College ❑ College Graduate
Mother’s Education Level (Check one) ❑ Not a High School Graduate ❑ High School Graduate ❑ Some College ❑ College Graduate
ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY (DO NOT ADD PARENT) (*Must provide at least a minimum of 3 emergency contacts (not counting parents) with address and telephone number)
NAMES OF PERSON AUTHORIZED TO TAKE CHILD FROM THE FACILITY (Contacts must be 18 years or older and present Photo ID) (Child will not be released to anyone without authorization on this form from parent or guardian)
Name shown on Identification Card Address Telephone Relationship to child *
( )
*
( )
*
( )
( )
( )
( )
( )
( )
PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY (Please complete this section and do not leave anything blank) Physician
Medical Plan & Number Telephone Number ( )
Dentist
Medical Plan & Number Telephone Number ( )
If Physician cannot be reached, what actions should be taken? ❑ CALL EMERGENCY HOSPITAL ❑ OTHER Explain: Signature of parent or guardian Date
For Office Only Publicity Release
❑ Yes ❑ No TO BE COMPLETED BY AUTHORIZED REPRESENTATIVE DATE OF ADMISSION:
DATE LEFT:
LIC 700 (ENG/SP) (5/OO) (CONFIDENTIAL) Rev 2/2017 BMcL
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICE COMMUNITY CARE LICENSING DIVISION
CHILD’S PREADMISSION HEALTH HISTORY—PARENT’S REPORT CHILD’S NAME SEX BIRTH DATE
FATHER’S NAME
DOES FATHER LIVE IN HOME WITH CHILD? If not, documentation is required.
MOTHER’S NAME
DOES MOTHER LIVE IN HOME WITH CHILD? If not, documentation is required.
IS /HAS CHILD BEEN UNDER REGULAR SUPERVISION OF PHYSICIAN?
DATE OF LAST PHYSICAL/MEDICAL EXAMINATION? Within 1 year of enrollment.
DEVELOPMENTAL HISTORY (*For infants and preschool-age children only) WALKED AT*
YEARS MONTHS BEGAN TALKING AT*
YEARS MONTHS TOILET TRAINING STARTED AT*
YEARS MONTHS PAST ILLNESSES – Check illnesses that child has had and specify approximate dates of illnesses
# Chicken Pox # Asthma # Rheumatic Fever
# Hay Fever
DATES
# Diabetes # Epilepsy # Whooping Cough
# Mumps
DATES
# Poliomyelitis # Ten-Day Measles (Rubeola) # Three-Day Measels
# (Rubella)
DATES
SPECIFY ANY OTHER SERIOUS OR SEVERE ILLNESSES OR ACCIDENTS
LIST ANY ALLERGIES STAFF SHOULD BE AWARE OF
DOES CHILD HAVE FREQUENT COLDS? ❑ YES ❑ NO
HOW MANY IN LAST YEAR?
DAILY ROUTINES (*For infants and preschool-age children only) WHAT TIME DOES CHILD GET UP? *
WHAT TIME DOES CHILD GO TO BED? * DOES CHILD SLEEP WELL?*
DOES CHILD SLEEP DURING THE DAY?
WHEN* HOW LONG?
DIET PATTERN: (What does child usually eat for these meals?)
BREAKFAST __________________________________________________________________
LUNCH __________________________________________________________________
DINNER __________________________________________________________________
WHAT ARE USUAL EATING HOURS?
BREAKFAST ___________________________
LUNCH ___________________________
DINNER ___________________________
ANY FOOD DISLIKES?
ANY EATING PROBLEMS?
IS CHILD TOILET TRAINED? If not, inform ❑ YES ❑ NO teacher and provide pull-ups & wipes.
IF YES, AT WHAT STAGE: * ARE BOWEL MOVEMENTS REGULAR?* ❑ YES ❑ NO
WHAT IS USUAL TIME?*
WORD USED FOR “BOWEL MOVEMENT”*
WORD USED FOR URINATION *
PARENT’S EVALUATION OF CHILD’S HEALTH
IS CHILD PRESENTLY UNDER A DOCTOR’S CARE? ❑ YES ❑ NO
IF YES, NAME OF DOCTOR: DOES CHILD TAKE PRESCRIBED MEDICATION(S)? ❑ YES ❑ NO
IF YES, WHAT KIND AND ANY SIDE EFFECTS:
DOES CHILD USE ANY SPECIAL DEVICE(S): ❑ YES ❑ NO
IF YES, WHAT KIND: DOES CHILD USE ANY SPECIAL DEVICE(S) AT HOME? ❑ YES ❑ NO
IF YES, WHAT KIND:
PARENT’S EVALUATION OF CHILD’S PERSONALITY HOW DOES CHILD GET ALONG WITH PARENTS, BROTHERS, SISTERS AND OTHER CHILDREN?
HAS THE CHILD HAD GROUP PLAY EXPERIENCES? DOES THE CHILD HAVE ANY SPECIAL PROBLEMS/FEARS/NEEDS? (EXPLAIN.) WHAT IS THE PLAN FOR CARE WHEN THE CHILD IS ILL? REASON FOR REQUESTING DAY CARE PLACEMENT PARENT’S SIGNATURE
DATE
LIC 702 (8/08) (CONFIDENTIAL)
Lennox School District 10319 Firmona Avenue, Lennox CA 90304
PARENT NEEDS ASSESSMENT Date: _____________________
Child’s Name:___________________________________________ School: ___________________________________
Parent’s Names: ____________________________________________________________________________________
Address: __________________________________________________________________________________________
Telephone Number: ________________________________ Alternative Number: _________________________________
Number in household: __________________ Language other than English in home: _______________________________
1. Do you need information or referrals in any of the following areas: (Check all that apply) !! Food Assistance! ! Family Counseling! ! Nutrition!! Housing! ! Parenting Education/Information! ! Crisis Intervention!! Home Buyer’s Assistance! ! GED Information! ! Gang/Crime Prevention!! Dental Referral ! ! ESL/Citizenship Information! ! Naturalization !! Employment Training! ! Employment! ! Transportation!! After School Program ! ! Legal Assistance! ! Health/Immunization!! Clothing! ! Tutoring! ! Medical/Insurance!! Recreational Activities! ! Counseling! ! Other: _________________________________!! Anti-Substance Abuse Training! ! Emergency Housing! ! !
2. Do you have any concerns about your child in any of the following areas: (Check all that apply)
! Hearing! ! Learning/Cognitive Development!! Vision! ! Social Development!! Speech/Language! ! Physical Development!! Behavior/Emotional Development! ! Other:____________________________ Specify!! Has your child attended other programs (i.e.: West Regional center, Carousel? If so which program?!
3. Parent Workshop Survey: (Select topics of interest)
! Literacy! ! Discipline! ! Language Acquisition!! Importance of Play! ! Nutrition/Health! ! Speech and Language!! Child Development! ! School Readiness! ! Conflict Resolution!! Preschool Foundations ! ! Curriculum: High Scope! ! Desired Results (Academic Progress) !
4. Parent Workshop Meeting Times and Days: (Select the best meeting time and day)! ! 8:15 AM! ! 11:00 AM! ! 3:00 PM! ! Monday! ! Wednesday! ! Friday!!! 5:00 PM! ! 6:00 PM! ! Other:! ! Tuesday! ! Thursday! ! Saturday!
______________________________________ __________________________________ Parent’s / Guardian’s Signature Date
FOR OFFICE USE ONLY Action Taken:________________________________________ Date: _______________________________ Follow Up: __________________________________________ Date: _______________________________ # Data inputted in Care Control # If any concerns in section 2 are checked, highlight and send to Disabilities Specialist with Birth Certificate # Attach any supporting documents from #2. Rev 2/2017 BMcL
CALIFORNIA DEPARTMENT OF EDUCATION CHILD DEVELOPMENT DIVISION CD9600A (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 childcare assistance.
PARENT/GUARDIAN: (Must be filled out by Head of Household) _____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 Type or print name Date CHILD’S NAME: ___________________________________ If you would like a copy of this form, please ask. 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. Form 9600A
!
Lennox School District
FAMILIES IN TRANSITION PROGRAM 10319 Firmona Ave. Lennox, CA, 90304
Tel. (310) 695-4000 Fax (310) 671-1795
STUDENT RESIDENCY QUESTIONNAIRE
This questionnaire is intended to address the McKinney-Vento Act, U.S.C.A Section 11302(a). Your answers will help the school determine residency documents necessary for enrollment and services to which you may be eligible.
Child’s Name Birthdate Age Male/Female Grade School
Pre-K
Siblings:
Name Birthdate Age Male/Female Grade School
1. The student lives with: "!1 Parent "!2 Parents "!1 Parent & another adult "!A relative "!An adult that is not the parent or legal guardian "!Alone with no adults 2. Presently, where is the student living? (Check all that apply): "!In a shelter (100) "!In a motel or hotel (110) "!In a transitional housing program (210) "!In a car, trailer or campsite (130) "!In a rented garage (130) "!In a rented trailer/motor home (130)
"!In our own apartment/house (200) "!Awaiting foster placement (210) "!Living/Renting with another family (120) "!Foster/group home placement (210) "!Renting a bedroom (120) "!Decline to state/Unknown "!Temporarily in another family’s house or apartment due to loss of housing (120) "!Temporarily with another adult that is not the parent/legal guardian due to loss of housing (210) "!Other___________________________________________ (300)
Name of Parent/Legal Guardian Phone
Address City Zipcode
Signature of Parent/Legal Guardian/Caretaker:
To be completed by District Office (FIT Coordinator/Liaison or Representative): "!Check if needs assessment was completed "!Enrolled in the free breakfast/lunch program "!Needs assessment completed and appropriate referrals made
Possible barriers to education: "!School Selection "!Transportation "!School Records "!Immunizations or other medical records "!Clothing/Uniforms "!Child Care "!Other:___________________________________________________
Eligible for any of these educational and school related activities and services: "!Special education (IDEA) "!English Language Learners (ELL) "!Gifted & Talented "!After School Program/Tutoring
Proposed Services to be provided: "!Transportation "!Counseling "!Before/after school, mentoring programs "!School Supplies "!Coordination between schools and agencies "!Clothing to meet a school requirement "!Parent Contact "!Parent Education related to rights/resources "!Medical, dental & Other health services referral
Attachment 1 McKinney
Identification Letter!
REV!2/2017!!
VERIFICATION OF RESIDENCY IN LENNOX SCHOOL DISTRICT
!!!!!!!!!!!!!
TO BE COMPLETED BY SCHOOL ENROLLING OFFICER
Three of the following verifications have been accepted as proof of Lennox School District Residency: Regular Driver’s License (not temporary). If the address has been modified or changed, completion of the Parent’s Affidavit of Residency, Form SS1b.
Bill statement for deposit with a local Utility company with parent name on it.
Bill statement for bills paid to local Utility company with parent name on it. If in different name that that of the student, the parent will be required to complete the Parent’s Affidavit of Residency.
Bank checkbook with name and address imprinted.
Title of Property or Rental Agreement (Contract).
Receipt for taxes (property taxes or taxes for personal property).
Delivery statement, etc...
Permit
Rental Agreement
Other
_____________________________ _____________________________ __________________ Enrolling Officer School Date
Rev 2/2017 BMcL
I, ___________________________, the parent or guardian
of ____________________________ am seeking to enroll
him/her in ____________________________ Preschool
and I certify under penalties of perjury, that the above-
named school-aged child, actually lives at
_______________________________________________
______________________________________________
and our telephone number is
(______) ______________________ which is located at
the above address.
___________________________________ Signature ___________________________________ Relationship to Enrollee(s) !
SECTION 4219.1 of the Inglewood Municipal Code read as follows: It shall be unlawful for any person to willfully make any false or misleading statement, either verbal or written, to any officer or employee of any school district within the City for the purpose of obtaining enrollment in such school district for any person.
Any violation of the Section shall be a misdemeanor and shall be punishable by a fine of not more than Five Hundred Dollars ($500), or by imprisonment in the City or County Jail for a period not exceeding six months, or by both such fine and imprisonment.
!Yo, ___________________________, el padre o tutor de
_______________________ pretendo inscribirlo en la
escuela ____________________ y certifico bajo penalidad
por perjurio que el niño nombrado en la actualidad vive en
_______________________________________________
______________________________________________
y nuestro numero de teléfono es
(_____)_________________________ el cual esta
localizado en la anterior dirección.
___________________________________ Firma ___________________________________ Parentesco con el niño
!
SECTION 4219.1 of the Inglewood Municipal Code read as follows: Será ilegal para que cualquier persona haga voluntariosamente cualquier declaración falsa o engañosa, verbal o escrita, a cualquier oficial o empleado de cualquier distrito escolar dentro de la cuidad con el propósito de obtener inscripción en el mencionado distrito escolar para cualquier persona.
Cualquier violación de la sección será un delito menor y será castigada por una multa de no mas de quinientos dólares ($500), o por el encarcelamiento en la cuidad o la cárcel del condado por un periodo que ne se excede seis meses, o con ambos.!
Parent’s Name
Child’s Name
School
Address
Address
Phone
Nombre de mama o papa
Nombre del niño
Escuela
Dirección
Dirección
Teléfono
El niño tiene alergias a los siguientes medicamentos: !
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING
CONSENT FOR EMERGENCY MEDICAL TREATMENT- Child Care Centers or Family Chi ld Care Homes
AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO ________________________________ TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.), OSTEOPATH (D.O.), OR DENTIST (D.D.S.) FOR _____________________________________. THIS CARE MAY BE GIVEN UNDER WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE.
________________ ______________________________ Date Parent or Authorized Representative Signature Address Home Phone Number Cell Phone Number Work Phone Number ( ) ( ) ( )
CONSENTIMIENTO PARA TRATAMIENTO MEDICO DE EMERGENCIA- Guarderías infantiles u hogares que proporcionan cuidado de niños
COMO PADRE/MADRE O REPRESENTANTE AUTORIZADO, DOY MI CONSENTIMIENTO PARA QUE _______________________ OBTENGA EL TRATAMIENTO MEDICO O DENTAL DE EMERGENCIA DEBIDAMENTE RECETADO POR UN DOCTOR CON LICENCIA (M.D.), OSTEOPATÍA (D.O.), O DENTISTA (D.D.S.) PARA _____________________________________. SE PUEDE PROVEER ESTE CUIDADO BAJO CUALQUIER CONDICIÓN QUE SEA NECESARIA PARA PRESERVAR LA VIDA, MIEMBROS DEL CUERPO, O EL BIENESTAR DEL NIÑO MENCIONADO ANTERIORMENTE.
________________ _________________________________ Fecha Nombre del Padre/Madre o Representante Autorizado Dirreción Número de teléfono de la casa Número de teléfono del cellular Número de teléfono del trabajo ( ) ( ) ( )
LIC 627 (9/08) (CONFIDENTIAL)
Child has the following medication allergies:
School’s Name
Child’s Name
Nombre del Escuela
Nombre del Niño
Lennox School District
10319 Firmona Avenue, Lennox CA 90304
El igibi l ity Verification Notice / Avisó de Verificación de Elegibi l idad
Date/ Fecha: ________________________________________ Parent/ Guardian’s Name/ Nombre de Padre o Guardián: ________________________________________ Child’s Name/ Nombre del Estudiante: ________________________________________ School Site/ Escuela: ________________________________________ The Lennox State Preschool is required by the California Department of Education (CDE) Child Development Division (CDD) to determine a family’s eligibility to receive state preschool services based on family size, income, or child protective services status. The use or disclosure of individual financial information concerning enrollees or their families will be limited to purposes connected with the administration of child care and development programs. The uses of this information includes, but is not limited to contact employers, medical or legal professionals, social workers, and/or other institutions or persons, in order to verify family eligibility. Any fraudulent, false, incomplete, deceitful, or misleading information provided to Lennox State Preschool regarding status of income or family size, that is used to determine initial eligibility, may be grounds for termination of state preschool services. Lennox State Preschool is required to recover costs from the parents or guardian for state preschool services at the time of initial enrollment. I understand that Lennox State Preschool has the right to verify information presented for the purpose of determining eligibility to receive state preschool services.
El Programa Preescolar Estatal de Lennox requiere que el Departamento de Educación de California (CDE) determine la elegibilidad del niño, de acuerdo al número de personas en la familia, ingresos o servicios de protección que recibe el niño. Esta información puede incluir: contactar a los empleadores, doctores, servicios legales, trabajadores sociales, y otras instituciones o personas para verificar la elegibilidad del niño. Cualquier información fraudulenta, falsa, incompleta o incorrecta que se proporcione para lograr la aceptación inicial basada en sus bajos ingresos, o número de personas que viven con usted, pueden ser causa para la terminación de este programa y deberán reembolsar y pagar todos los gastos ocasionados desde que se registró el niño en el Programa Preescolar Estatal de Lennox. Yo entiendo que el Programa Preescolar Estatal de Lennox tiene derecho de verificar la información presentada con el propósito de determinar la elegibilidad para recibir estos servicios.
__________________________________________________ ______________________ Parent/Guardian’s Signature/ Firma del Padre/Guardián Date/Fecha __________________________________________________ ______________________ Agency Representative/ Representante de la Agencia Date/Fecha
Rev 2/17 BMcL
Lennox School District 10319 Firmona Avenue, Lennox CA 90304
Publ ication Release Form Lennox School District 10319 Firmona Ave. Lennox, CA 90304
Parents, it is possible that your child may be photographed or videotaped while participating in any school functions for a
variety of publicity purposes, such as; community newspapers, school district slide/picture presentations, brochures, videos,
the Internet or other similar district publications. Their name may also be included in these publications.
Your child’s name: __________________________________________________ (first and last name of child) Please check one: #Yes, I give permission to allow my child to be photographed/videotaped and to use his/her first name in publications. #No, I do not give permission to allow my child to be photographed/videotaped and to use his/her first name in publications. Signature of Parent: ____________________________________________________ Date: ____________________
Formulario de Autorización de Publ icación Distrito Escolar de Lennox
Padres, es posible que su hijo/a sea fotografiado o grabado en video durante su participación en eventos escolares para una
variedad de publicaciones, tales como: periódicos de la comunidad, fotos para presentaciones del distrito escolar, folletos,
videos, publicaciones del Internet u otras publicaciones similares del distrito. Además su nombre podría ser incluido en estas
publicaciones.
Nombre de su hijo/a: ____________________________________________________ (nombre y apellido del niño/a) Por favor marque uno: #Sí, doy permiso para que mi hijo sea fotografiado / filmado y usar su nombre en las publicaciones.
#No, doy permiso para que mi hijo sea fotografiado / filmado o usar su nombre en las publicaciones. Firma del padre: _____________________________________________________ Fecha: ______________________
STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION
CHILD CARE CENTER NOTIFICATION OF PARENTS’ RIGHTS
PARENTS’ RIGHTS
As a Parent/Authorized Representative, you have the right to:
1. Enter and inspect the child care center without advance notice whenever children are in care. We have an open
door policy.
2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office.
3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. Complain to the licensing office and inspect the family child care home without discrimination or
retaliation against you or your child.
4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.
5. Request in writing that a parent not be allowed to visit your child or take your child from the child care center, provided you have shown a certified copy of a court order.
6. Receive from the licensee the name, address and telephone number of the local licensing office.
Licensing Office Name: _________________________________________________________________
Licensing Office Address: _________________________________________________________________ Licensing Office Telephone #: ________________________________________________________________
7. Be informed by the licensee, upon request, of the name and type of association to the child care center for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office.
8. Receive, from the licensee, the Caregiver Background Check Process form.
NOTE: CALIFORNIA STATE LAW PROVIDES THAT THE LICENSEE MAY DENY ACCESS TO THE FAMILY CHILD CARE HOME TO A PARENT/AUTHORIZED REPRESENTATIVE IF THE BEHAVIOR OF THE PARENT/AUTHORIZED REPRESENTATIVE POSES A RISK TO CHILDREN IN CARE.
For the Department of Justice “Registered Sex Offender”database, go to www.meganslaw.ca.gov
LIC 995 (9/08) (Detach Here - Give Upper Portion to Parents) -------------------------------------------------------------------------------------------------------------------------------------------------
ACKNOWLEDGEMENT OF NOTIFICATION OF PARENTS’ RIGHTS (Parent/Authorized Representative Signature Required)
I, the parent/authorized representative of ____________________________________, have received a copy of the “FAMILY CHILD CARE HOME
NOTIFICATION OF PARENTS’ RIGHTS”, the CAREGIVER BACKGROUND CHECK PROCESS and the FAMILY CHILD CARE CONSUMER
AWARENESS INFORMATION form from the licensee.
Buford Felton Jefferson Moffett Whelan Name of Family Child Care Home/School (Circle one)
______________________________________________ __________________ Signature (Parent/Authorized Representative) Date
NOTE: This Acknowledgement must be kept in child’s file and a copy of the Notification given to the parent/authorized representative.
LIC 995 (9/08)
Child’s Name!
Los Angeles Daycare NW, Care Licensing Office
6067 Bristol Parkway, Suite 400, Culver City, CA 90230
310-337-4333
STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PERSONAL RIGHTS Child Care Centers Personal Rights, See Section 101223 for waiver conditions applicable to Child Care Centers. (a) Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following:
(1) To be accorded dignity in his/her personal relationships with staff and other persons.
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
(4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality.
(5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s) or guardian(s) of the child. We refrain from religious instruction.
(6) Not to be locked in any room, building, or facility premises by day or night.
(7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency.
THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: ______________________________________________________________________________________________________________________ NAME
______________________________________________________________________________________________________________________ ADDRESS
______________________________________________________________________________________________________________________ CITY ZIP CODE PHONE
DETACH HERE ✂----------------------------------------------------------------------------------------------------------------------------------------------
TO: PARENT/GUARDIAN/CHILD OR AUTHORIZED REPRESENTATIVE: Upon satisfactory and full disclosure of the personal rights a explained, complete the following acknowledgment: ACKNOWLEDGMENT: I/We have been personally advised of, and have received a copy of the personal rights contained in the California Code of Regulations, Title 22, at the time of admission to:
(CIRCLE THE NAME OF THE FACILITY) # Buford State Preschool # Felton State Preschool # Jefferson State Preschool # Moffett State Preschool # Whelan State Preschool
(CHECK THE ADDRESS OF THE FACILITY) # Buford: 10915 Felton Avenue # Felton: 10417 Felton Avenue # Jefferson: 10203 Firmona Avenue # Moffett: 11050 Larch Avenue # Whelan: 4125 105th Street
(PRINT THE NAME OF THE CHILD)
(SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN)
(TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN)
! Mother ! Father ! Guardian
(DATE)
LIC 613A (8/08)
Los Angeles Daycare NW, Care Licensing Office
6067 Bristol Parkway, Suite 400, Culver City, CA 90230 310-337-4333
PLACE IN CHILD'S FILE
Lennox School District 10319 Firmona Avenue, Lennox CA 90304
HOME LANGUAGE SURVEY Directions to Parents and Guardians: The California Education Code contains legal requirements, which direct schools to determine the language(s) spoken in the home of each student. This information is essential in order for the school to provide adequate instructional programs and services. As parents or guardians, your cooperation is requested in complying with this legal requirement. Please respond to each of the four questions listed below as accurately as possible. For each question, write the name(s) of the language(s) that apply in the space provided. Please do not leave any questions unanswered.
(1) Name of Student _____________________________ __________________________ _________________________ Surname / Last Name First Give Name Second Given Name (2) Age of Student: _________________ Grade Level: ________ 1. Which language did your child learn when he/she first began to talk? _____________________________ 2. Which language does your child most frequently speak at home? _____________________________ 3. Which language do you (the parents or guardians) most frequently use _____________________________ when speaking with your child? 4. Which languages are most often spoken by adults in the home? _____________________________ (parents, guardians, grandparents, or any other adults)
Please sign and date this form in the spaces provided below. Thank you for your cooperation. ____________________________________________________ _____________________________ (Signature of parent or guardian) (Date)
NOTE OFFICE USE ONLY School district should complete all the information items below this line.
School (Circle One) BUFORD – FELTON – HUERTA – JEFFERSON – MOFFETT – LENNOX MIDDLE SCHOOL Teacher Name:__________________________________________
Form%HLS,%Revised%October%2005%%%%%%%California%Department%of%Education%
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______________________________________________
Employer/Compañia
______________________________________________ Address/Domicilio
______________________________________________
Telephone/Teléfono
______________________________________________ Hours of operation/ Horas de operación
Release Authorization of Employment
Autorización de Empleo
I, ____________________________ authorize Lennox School District State Preschool Program to verify employment from by employer. Yo, ____________________________ autorizo al Programa Preescolar del Distrito de Lennox para que verifique mi empleo de mi empleador.
M y work schedule / Horario de trabajo Sunday: _________ am/pm - _________ am/pm
Monday: _________ am/pm - _________ am/pm
Tuesday: _________ am/pm - _________ am/pm
Wednesday: _________ am/pm - _________ am/pm
Thursday: _________ am/pm - _________ am/pm
Friday: _________ am/pm - _________ am/pm
Saturday: _________ am/pm - _________ am/pm
Date Hired/Fecha que comenzo empleo: _____________
__________________________________________________________ ______________________________ Parent’s Signature/Firma del Padre/Madre Date/Fecha ! !Release Authorization of Employment
Autorización de Empleo
I, ____________________________ authorize Lennox School District State Preschool Program to verify employment from by employer. Yo, ____________________________ autorizo al Programa Preescolar del Distrito de Lennox para que verifique mi empleo de mi empleador.
__________________________________________________________ ______________________________ Parent’s Signature/Firma del Padre/Madre Date/Fecha !
______________________________________________
Employer/Compañia
______________________________________________ Address/Domicilio
______________________________________________
Telephone/Teléfono
______________________________________________ Hours of operation/ Horas de operación
M y work schedule / Horario de trabajo Sunday: _________ am/pm - _________ am/pm
Monday: _________ am/pm - _________ am/pm
Tuesday: _________ am/pm - _________ am/pm
Wednesday: _________ am/pm - _________ am/pm
Thursday: _________ am/pm - _________ am/pm
Friday: _________ am/pm - _________ am/pm
Saturday: _________ am/pm - _________ am/pm
Date Hired/Fecha que comenzo empleo: _____________
PHYSICIAN’S REPORT – SCHOOL CENTERS (CHILD’S PRE-ADMISSION HEALTH EVALUATION) !
PART A – PARENT’S CONSENT (TO BE COMPLETED BY PARENT)
______________________________________ , born _______________________________ is being studied for readiness to enter
the _____________________________________ . This Child Care Center/School provides a program, which extends from 7:50 am
to 10:50 am or 12:00 pm to 3 pm, five days a week.
Please provide a report on above-named child using the form below. I hereby authorize release of medical information contained in this report to the above named Child Care Center. ____________________________________________________________________ _______________________ Signature of Parent, Guardian, or Child’s Authorized Representative Date PART B – PHYSICIAN’S REPORT (TO BE COMPLETED BY PHYSICIAN) Problems of which you should be aware: Hearing: Allergies: medicine: Vision: Insect stings: Developmental: Food: Language/Speech: Asthma: Other (Include behavioral concerns): Dental: Comments/Explanations: MEDICATION PRESCRIBED/SPECIAL ROUTINES/RESTRICTIONS FOR THIS CHILD: MEDICATION PRESCRIBED/SPECIAL ROUTINES/RESTRICTIONS FOR THIS CHILD: IMMUNIZATION HISTORY: (Fill out or enclose California Immunization Record, PM – 298.) Vaccine Date Each Dose Was Given
1st 2nd 3rd 4th 5th POLIO (OPV OR IPV)
DTP/DtaP/DT/Td
MMR (Measles, Mumps, and Rubella)
HIB Meningitis (Required for Child Care Only)
Hepatitis B
Varicella Chickenpox)
Hepatitis A
Pnuemocococcal
Tuberculosis Test done on: ____________________ No Risk Factor Date Given: _______________ Date Read:________________ Results ________
Have Have not reviewed the above information with the parent/guardian. Physician:
Date of Physical Exam:
Stamp:
Date this Form Completed: Signature:
Form completed by:
Physician
Physician’s Assistant
Nurse Practitioner
Rev 2/2017 BMcL
NAME OF CHILD BIRTHDATE
NAME OF SCHOOL
