Embed Size (px)
Citation preview
STUDENT REGISTRATION INFORMATION (Grades TK-12) PETALUMA CITY (ELEMENTARY) AND JOINT UNION HIGH SCHOOL DISTRICTS
School of Residence Year 20 -20 Date
Schools Requested (in choice order): 1. 2. 3.
Student's Legal Name Gender Grade Last First Middle
Birthdate / / Birthplace Entered U.S.A / / Entered U.S.A. school / / MM I DD I YYYY MM I DD I YYYY MM I DD I YYYY
Primary phone Mailing Address Apt. # City
Home Address Apt. # City
Zip Code
Zip Code
Name of Father/Legal Guardian Employer Last First
Occupation Daytime phone Cell phone Email
Name of Mother/Legal Guardian Employer Last First
Occupation Daytime phone Cell phone Email
Name of Other Legal Guardian Employer Last First
Occupation Daytime phone Cell phone Email
STUDENT LIVES WITH (Check all that apply): Father Mother Stepfather Stepmother Grandfather Grandmother Uncle Aunt Legal Guardian(s) Other Conditions:
Are parents separated? Yes No if so, may other parent pick up child at school? Yes No
(SUPPORTIVE LEGAL DOCUMENT REQUIRED) LEGAL CUSTODY PAPERS ON FILE
2nd Mailing Address Apt. # City Zip Code
Brothers/sisters (living at home)* Date of Birth Age If school age, name of school
Name
Name
Name
*If more than 3 children living at home, please attach a separate sheet.
Previous School Attended Name of School Street Address City State Zip Code
ls your student currently under an expulsion order at another district or being recommended for expulsion? Yes No
SPECIAL PROGRAMS
Does your son/daughter have an lEP, 504 plan, or receive speech services? Yes No
& SPECIAL EDUCATION If yes, please specify and attach IEP or 504
Has your son/daughter been identified as a Gifted and Talented Education (GATE) student? Yes No
Any special health considerations or allergies (please indicate if an EpiPen is prescribed)
PC73/PC 74 (1/2017) Page 1 of 2
___ ___ ___ ___ ___ ___ ___ ___
___ __
___ __
INFORMACION DE ESTUDIANTE(Grades TK-12)
PETALUMA CITY (ELEMENTARY) AND JOINT UNION HIGH SCHOOL DISTRICTS
Escuela de Residencia Año 20 -20 Fecha
Escuela Solicitada (en orden de elección): 1. 2. 3.
Nombre Legal del Estudiante Sexo Grado Apellido Primer Nombre Segundo Nombre
Fecha de Lugar de Fecha de Fecha de entrada Nacimiento / / Nacimiento entrada a EE.UU / / a la Escuela en EE.UU /_ /
Mes/Día /Año Mes / Día / Año Mes / Día / Año
Numero de Telefono
Dirección de Correo Apto. # Ciudad
Dirección de Su Casa Apto. # Ciudad
Código Postal
Código Postal
Nombre de Padre/Guardián Legal Empleador Apellido Primer Nombre
Ocupación Teléfono de Día Celular Email
Nombre de Madre/ Guardián Legal Empleador
Apellido Primer Nombre
Ocupación Teléfono de Día Celular Email
Nombre de Otro Guardián Legal Empleador
Apellido Primer Nombre
Ocupación Teléfono de Día Celular Email
ESTUDIANTE VIVE CON (Marque lo que aplique): Padre Madre Padrastro Madrastra Abuelo Abuela Tío Tía Guardián Legal(es) Otro Condiciones:
¿Están los padres separados? Sí No si contestó Si, ¿puede el otro padre recoger al estudiante de la escuela? Yes No
(SON NECESARIOS LOS DOCUMENTOS LEGALES) PAPELES DE CUSTODIA LEGAL EN EL ARACHIVO
2da dirección de Correo Apto. # Ciudad Código Postal
Hermanos/hermanas (que viven en casa)* Fecha de Nacimiento Edad Si va a la escuela, nombre de la escuela
Nombre
Nombre
Nombre
*Si más de 3 niños viven en la casa, por favor adjunte otra hoja
Escuela Anterior Nombre de la Escuela Dirección Ciudad Estado Código Postal
Está su estudiante bajo orden de expulsión en otro distrito o está siendo recomendado para expulsión? Sí No
PROGRAMAS ESPECIALES
¿Tiene su hijo/a un IEP, plan 504, o recibe servicios de terapia de lenguaje? Sí No Si contesta sí, por favor especifique
¿Ha sido su hijo/a identificado como estudiante dotado y Talentoso (GATE)? S í No
Alguna consideración especial de salud o alergias (por favor, indique si le han prescripto EpiPen )
PC73/PC 74 (12/2016) Page 1 of 2
STATE MANDATED COMPLIANCE INFORMATION
PETALUMA CITY (ELEMENTARY) AND JOINT UNION HIGH SCHOOL DISTRICTS
Student’s Legal Name Last First Middle
Birthdate
I. Parent Education level: Check one response that best applies for each parent/guardian:
Father/guardian: Mother/guardian: Not a high school graduate College graduate Not a high school graduate College graduate High school graduate Grad school/past grad training High school graduate Grad school/past grad training Some college Decline to state or unknown Some college Decline to state or unknown
II. Ethnicity: Is your student Hispanic or Latino? (Choose only one)
Yes, Hispanic or Latino. (This includes all persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)
No, not Hispanic or Latino.
III. Race: What is your student’s race? (Please answer this question regardless of your response to question II. above. Mark any that apply.)
American Indian or Alaskan Native (A person having origins in any of the original peoples of North and South America, including
Central America, AND who maintains tribal affiliation or community attachment.)
Black/African American Other Pacific Islander Vietnamese
Filipino/Filipino American Chinese Hmong
Hawaiian Japanese Laotian
Samoan Korean Cambodian
Guamanian Asian Indian Other Asian
Tahitian
White (A person having origins in any of the original peoples of Europe, the Middle East or North Africa.)
IV. IV. Home Language Survey
The California Education Code requires schools to determine the language(s) spoken at home by each student. This information is essential in order to provide meaningful instruction for all students.
1. Which language did your child learn when he/she first began to talk?
2. What language does your son or daughter use most frequently athome?
3. What language do you use most frequently to speak to your son or daughter?
4. Name the language most often spoken by the adults athome.
Y In what language do you wish the school to communicate with you? English Spanish (please check only one)
Y Are you a refugee? Yes No If yes, from what country? Date entered U.S.A. I-94 #
Y Is at least one parent/guardian of this student active in the United States Armed forces? Yes No
l declare under penalty of perjury (under the laws of the United States of America) that the foregoing is true and correct.
Signature of parent/guardian filling outthis form Date
OFFICE Verification of Residency Verified by USE
ONLY Verification of Birthdate Verified by
Interdistrict Permit Intradistrict Permit Permanent Needed? Y N Needed? Y N ID Number
Final School Placement: Verified by
PC73/PC 74 (1/2017) Print Reset
Page 2 of 2
___ ___
___
___ ___
___
__ __
__
__ __
__
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
INFORMATION OBLIGATORIA CONFORME AL MANDATO DEL ESTADO
PETALUMA CITY (ELEMENTARY) AND JOINT UNION HIGH SCHOOL DISTRICTS
Nombre Legal del Estudiante Apellido Primer Nombre Segundo Nombre
Fecha de Nacimiento
I. Nivel de Educación de los Padres: Marque le mejor respuesta de información para el padre/la madre.
Padre: Madre:
No se graduó de preparatorio Graduado de universidad _ Graduado de preparatorio Estudio de post-grado _ Alguna universidad No quiere dar información _
_No se graduó de preparatorio _ _Graduado de preparatorio _
_Alguna universidad _
_ Graduado de universidad _ Estudio de post-grado _ No quiere dar informacíon
o no sabe o no sabe
II. Étnicidad: ¿Es su hijo(a) Hispano(a) o Latino(a)? (Marque sólo uno)
_ Sí, Hispano(a) o Latino(a). (Esto incluye a personas de Cuba, México, Puerto Rico, Sur o Centro América, u otra cultura u origen español sin importar la raza.)
_ No, no es Hispano(a) o Latino(a).
III. Raza: ¿Qué raza es su hijo(a)? (Por favor, conteste esta pregunta sin importar su respuesta a la pregunta II. arriba. Marque todo lo que corresponda.)
_ Indio Americano o nativo de Alaska (Una persona que tenga orígenes en cualquiera de las personas nativas de Norte y Sur América,
incluyendo América Central, Y quien mantenga afiliación a tribus o sea parte de esa comunidad.)
_ Negro/Americano Africano _
_ Filipino/Filipino Americano _
_ Hawaiano _
_ Samoano _
_ Guamayano _
_ Tahitiano
Otro Isleño del Pacífico _
Chino _
Japonés _
Coreano _
Hindú _
Vietnamés
Hmong
Laosiano
Camboyano
Otro Asiático o Isleño del Pacífico
_ Blanco (Una persona que tenga orígenes en cualquiera de las personas originales de Europa, el Medio Oriente, o África del Norte.)
IV. Cuestionario del Idioma Natal
El Código de Educación de California requiere que las escuelas determinen el/los idioma(s) hablado(s) en el hogar por cada estudiante. Esta información es esencial para proveer una instrucción significante para todos los estudiantes.
1. ¿Qué idioma aprendió su hijo(a) cuando empezó a hablar?
2. ¿Qué idioma usa su hijo(a) más frecuente en la casa?
3. ¿Qué idioma usa más frecuente para hablar con su hijo(a)?
4. ¿Cuál es el idioma que los adultos hablan más a menudo?
➢ ¿Cuál idioma quiere que use la escuela para comunicarse con usted ? Inglés Español (por favor marque uno)
➢ ¿Es usted un refugiado? Sí No Si contesta sí, ¿de qué país? Fecha de entrada en los EE.UU. 1-94 #
➢ ¿ Es al menos un padre / guardián legal de este alumno activo en las fuerzas armadas de Estados Unidos? Si No
Yo declaro bajo pena de perjurio (bajo las leyes de los Estados Unidos de América) que lo anterior es verdadero y correct.
Firma de padre/guardián que llenó el formulario Fecha
OFFICE Verification of Residency Verified by
USE ONLY Verification of Birthdate Verified by
Interdistrict Permit Intradistrict Permit Permanent Needed? Y N Needed? Y N ID Number
Final School Placement: Verified by
PC73/PC 74 (12/2016) Impresión Reiniciar Page 2 of 2
GUIDELINES FOR STUDENT EMERGENCY TREATMENT FORM
Parents or Guardians:
Please be aware that the information listed on the attached form is needed to contact you or a designated individual in the case of an emergency directly related to your child and/or a campus-wide or community emergency.
Any contact you list should be able to come to your child's school within 30 minutes.
Our automated dialer phone system will attempt to contact the primary phone number
that you provide on this form.
Please pick a phone number that is most likely to be answered by you.
We ask that you provide at least one email address for electronic communications.
DIRECTRICES PARA EL FORMULARIO DE TRATAMIENTO DE
EMERGENCIA DEL ESTUDIANTE
Padres o Guardianes:
• Tenga en cuenta que la información que se detalla en el formulario adjunto es necesaria para contactarlo a usted o a un individuo designado en el caso de una emergencia relacionada directamente con su hijo y / o una emergencia comunitaria o en todo el campus.
Cualquier contacto que liste debe poder llegar a la escuela de su hijo dentro de los 30
minutos.
• Nuestro sistema de marcado telefónico automático intentará contactar al número de teléfono principal que usted proporciona en este formulario.
• Elija un número de teléfono que sea más probable que usted sea quien conteste..
• Le pedimos que proporcione al menos una dirección de correo electrónico para las
comunicaciones electrónicas.
Student Emergency Treatment Authorization
I/We the undersigned, parent(s) of the above, a minor, do hereby authorize the principal or designee as agent for the undersigned to consent to any x-ray, examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by , and is to be rendered under the general or special supervision of any physician and surgeon licensed under the provisions of the Medicine Practice Act, whether such a diagnosis or treatment is rendered at the office of said physician or at said hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power on the part of our aforesaid agents(s) to vie specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician in the exercise of their best judgment may deem advisable.
This authorization shall remain effective until the end of the current school year, unless revoked in writing delivered to said agents(s)
Student Name
Primary Care Physician’s Name Insurance Carrier
Parent/Guardian Signature Date
Formulario para Tratamiento del Estudiante en caso de Emergencia Yo/nosotros los abajo firmantes, padres del anterior, un menor de edad, autorizo(amos) al director o persona designada como agente de los firmantes, a dar consentimiento a cualquier rayos x, examen, anestésico, diagnóstico o tratamiento médico o quirúrgico y atención en hospital que se considere aconsejable por, y es prestados bajo la supervisión general o especial de cualquier médico y cirujano licenciado bajo las disposiciones de la Ley de Práctica de la Medicina, si tal diagnóstico o tratamiento es prestado en la oficina de dicho médico o en dicho hospital. Se entiende que esta autorización se da por adelantado de cualquier diagnóstico específico, cuidado, tratamiento o cuidado de hospital necesario, pero se da para proporcionar la autoridad y el poder por parte de nuestros agentes mencionados, a dar consentimiento específico para alguno y todos tales diagnósticos, tratamiento o cuidado de hospital que el médico mencionado en el ejercicio de su mejor juicio estime conveniente.
Esta autorización permanecerá vigente hasta el final del año escolar actual, a no ser que sea revocada por escrito y entregada a dichos agentes.
Nombre de estudiante:
Nombre de Doctor: Seguro Médico:
Firma de Padres/Guardián Fecha
4/10/2015
STUDENT HEALTH SERVICES
MEDICAL CONSENT FOR TREATMENT OF A MINOR
Student’s Name
Social Security
Date of Birth
(I) (We), the undersigned parent(s)/guardian(s) to , a minor, do hereby consent to any x-ray examination, anesthetic, medical or surgical evaluation, diagnosis or treatment that may be rendered to said minor child under the general or special supervision of physician or surgeon licensed under the provisions of the California Medical Practice Act, whether such diagnosis or treatment is rendered at Santa Rosa Junior College – Student Health Services or at a licensed hospital, clinic, or doctor’s office.
It is understood that this consent is given in advance of any specific diagnosis or treatment being required, but is given to provide authority and power to render care which the staff of the SRJC Student Health Services in the exercise of their best judgment may deem advisable.
It is understood that in case of an emergency, reasonable efforts shall be made to contact the undersigned prior to rendering treatment to the patient, and that any of the above treatment will not be withheld if the undersigned cannot be reached.
This consent is given pursuant to the provisions of Section 25.8 of the California Civil Code.
Signature Parent or Legal Guardian (please print) Date
Address City State Zip
Telephone where Parent/Legal Guardian can be reached:
Name: Home: Work: (please print)
This form is designed to permit the Santa Rosa Junior College – Student Health Services to evaluate and treat your child until she or he reaches the age of 18 unless sooner revoked in writing. It allows our office to provide the following services at each visit without requesting verbal or written consent from you:
1. Routine student health care. (For problems such as colds, minor injuries and illnesses, cuts requiring tetanus immunization, etc.)
2. Emergency care, first aid, and referral to local health facilities should an emergency situation arise while your child is on the SRJC campuses.
If you have any questions regarding this form, you are welcome to call the Student Health Services office at (707) 527 – 4445 and talk to one of our Nurse Practitioners on duty.
SERVICIOS DE SALUD
ESTUDIANTIL CONSENTIMENTO MEDICO PARA EL TRATAMIENTO DE UN MENOR
Nombre del Estudiante _
Seguro Social _
Fecha de Nacimiento
(I) (Nosotros), el (los) padre (s) / tutor (es) firmante (s) de un menor de edad, por el presente consiento en cualquier examen de rayos X, anestesia, evaluación médica o quirúrgica, diagnóstico o tratamiento que pueda ser prestado a dicho menor niño bajo la supervisión general o especial del médico o cirujano licenciado según las disposiciones de la Ley de Práctica Médica de California, ya sea que dicho diagnóstico o tratamiento se brinde en Santa Rosa Junior College - Servicios de Salud Estudiantil o en un hospital, clínica o consultorio médico autorizado.
Se entiende que este consentimiento se brinda antes de que se requiera un diagnóstico o tratamiento específico, pero se proporciona para otorgar autoridad y poder para prestar atención que el person al de los Servicios de Salud Estudiantil de SRJC pueda juzgar conveniente en el ejercicio de su mejor juicio.
Se entiende que, en caso de una emergencia, se deben realizar esfuerzos razonables para contactar al suscrito antes de darle tratamiento al paciente, y que cualquiera de los tratamientos anteriores no se retendrá si no se puede contactar al suscrito.
Este consentimiento se otorga de conformidad con las disposiciones de la Sección 25.8 del Código Civil de California.
Firma/Nombre del Padre/Tutor Fecha
Ciudad Estado Código Postal
Teléfono donde se puede contactar al padre / tutor legal:
Nombre: Casa: Trabajo: _ _ _ _
Este formulario está diseñado para permitir que Santa Rosa Junior College - Student Health Services evalúe y trate a su hijo hasta que cumpla los 18 años, a menos que lo revoque antes por escrito. Permite a nuestra oficina brindar los siguientes servicios en c ada visita sin solicitar su consentimiento verbal o por escrito:
1. Cuidado de salud rutinario del estudiante. (Para problemas tales como resfriados, lesiones y enfermedades menores, cortes que requieren inmunización contra el tétanos, etc.)
2. Atención de emergencia, primeros auxilios y derivación a centros de salud locales en caso de que surja una situación de emergencia mientras su hijo esté en el campus de SRJC.
Si tiene alguna pregunta sobre este formulario, puede llamar a la oficina de Servicios de Salud para Estudiantes al (707) 527 - 4445 y hablar con una de nuestras enfermeras practicantes de turno.
STUDENT EMERGENCY/TREATMENT FORM
Please PRINT information ◊ Return to School Office
Student’s Name: Birthdate: / /
Student Cell # (optional): Grade: M F
Address: , Street Address City Zip Code
Primary Phone: Secondary Phone:
Mother’s Name: Work #: Cell #: E-Mail:
Father’s Name Work #: Cell #: E-Mail:
Student lives with: Both Parents Mother Father Step-Parent Legal Guardian Other/Explain:
In case of illness or emergency, list the names & contact information for 3 people to whom we can release your child, :
1. Contact Name: Phone: Phone: Relationship:
2. Contact Name: Phone: Phone: Relationship:
3. Contact Name: Phone: Phone: Relationship:
Student’s Doctor: Phone: Permission to Contact Doctor: Yes No
Health Insurance Carrier: Insurance #:
HEALTH INVENTORY
In order to provide the best educational program for your child, the school would appreciate you providing the following health information.
Please check which of the following conditions your child has and whether he/she is still under care of a physician for this condition.
Condition
Limitations
Medications/Dosage Under
Physician’s Care Allergies, Food/Other (List) Epi Pen Yes No Yes No Asthma Yes No Bee Sting Allergy: Epi Pen Yes No Yes No Heart Condition Yes No Diabetes Yes No Kidney Disease Yes No Epilepsy/Seizure: Type Yes No Frequent or Severe Headache Yes No Depression/Anxiety Disorder (circle one) Yes No Other physical/mental condition: Yes No
Does your child have any condition, which could be a school emergency? Yes No Explain:
Is your child presently taking any medicine not listed above? Yes No Explain:
Name of Medicine : Time of day medicine is taken:
I/We the undersigned, parent(s) of the above, a minor, do hereby authorize the principal or designee as agent for the undersigned to consent to any x-ray, examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any physician and surgeon licensed under the provisions of the Medicine Practice Act, whether such a diagnosis or treatment is rendered at the office of said physician or at said hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power on the part of our aforesaid agent(s) to vie specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician in the exercise of their best judgment may deem advisable.
This authorization shall remain effective until the end of the current school year, unless revoked in writing delivered to said agent(s).
Signature of Parent/Guardian: Date:
Form EMERG-38 Revised 5/12
FORMULARIO DE EMERGENCIA/TRATAMIENTO DEL ESTUDIANTE
Por favor IMPRIMA ◊ Devuelva a la oficina de la escuela
Nombre del Estudiante: Fecha de Nacimiento: / /
Celular del Estudiante (opcional): Grado: M F
Domicilio: , Calle Ciudad Código Postal
Teléfono Principal: Teléfono Adicional:
Nombre de Madre: # Trabajo: Celular E-Mail:
Nombre de Padre # Trabajo: Celular: E-Mail:
Estudiante vive con: Ambos Padres Madre Padre Padrastro/Madrastra Guardián Legal Otro/Explique:
En caso de enfermedad o emergencia liste el nombre y la información de 3 personas a quienes puedamos entregar a su hijo/a, :
1. Nombre : Teléfono: Teléfono: Relación:
2. Nombre : Teléfono: Teléfono: Relación:
3. Nombre : Teléfono: Teléfono: Relación:
Doctor del Estudiante: Teléfono: Permiso para contactar al Doctor: Si No
Nombre del Seguro de Salud: Póliza de Seguro#:
INVENTARIO DE SALUD
En orden de proporcionar el mejor programa educativo para su hijo(a), la escuela aprecia que le provea la siguiente información de salud.
Por favor, marque cual condición(es) padece su hijo(a) y si el/ella está bajo el cuidado de un médico for esa condición.
Bajo co
Padece su hijo(a) alguna condición, que pueda resultar en una emergencia en la escuela? Si No Explique:
Esta su hijo(a) tomando alguna medicina no listada arriba? Si No Explique:
Nombre de la Medicina : Hora del día en que toma la medicina:
Yo/Nosotros quienes firmamos abajo, padre(s) del menor de edad nombrado arriba, autorizo(amos) al director o designatario como agente para los firmantes a dar su consentimiento para cualquier rayos x, exámen, anestésico, diagnóstico o tratamiento médico o quirúrgico y cuidado de hospital que se estime conveniente por, y sea prestado bajo la supervisión general o especial de cualquier médico o cirujano con licencia conforme a la Ley de Práctica de Medicina, si dicho diagnóstico o tratamiento toma lugar en la oficina de dicho médico en dicho hospital. Se entiende que esta autorización está dada antes de que cualquier diagnóstico específico, tratamiento o cuidado de hospital sea necesario pero es dada para propor- cionar autoridad y poder en la parte de nuestro(s) agente(s) mencionados para emular consentimiento específico para cualquiera y todos dichos diagnosticos, tratamientos o cuidado de hospital que el médico mencionado en el ejercicio de su mejor juicio estime conveniente.
Esta autorización permanecerá efectiva hasta el final de este año escolar, a no ser que sea revocada por escrito y entregada a dicho agente(s).
Firma de Padre/Guardián: Fecha:
Form EMERG-38 Revised 4/12
Condición Alergias, Alimentos/Otro Epi Pen Si No Asma
Limitaciones
Medicación/Dósis
Cuidado Médi Si No Si No
Picada de Abeja: Epi Pen Si No Si No Condición Cadíaca Si No Diabetis Si No Enfermedad de Riñón Si No Epilepsia/Ataques de Epilepsia: Tipo: Si No Dolores de Cabeza Frecuentes Si No Depresión/Ansiedad (circule uno) Si No Otra condición física/mental : Si No
Student Residency Questionnaire Petaluma City Schools District
This questionnaire is intended to address the McKinney-Vento Homeless Education Assistance Improvement Act. The confidential answers to this questionnaire help determine the services the student may be eligible to receive.
1. Student’s Name: ___________________________________________________________ * Male * Female Please Print Full Name
Date of Birth: _______/_______/________ Age: ______ Contact Phone #: _________________
2. Is your address a temporary arrangement? _____Yes _____No If the answer is yes, please complete the remaining sections of this form.
3. Is this temporary living arrangement due to loss of housing and/or economic hardship?
4. Parent/Guardian Name(s): ________________________________________________________________________
Please Print Full Name
Relationship to Student (i.e., mother, father, grandparent, uncle, aunt, friend): ________________________________
Address: ______________________________________________________________________________ _______
City: ________________________________ Zip: __ Contact Phone #: ____________________________
Signature: ______________________________________________________________________________________
Where is the student presently living? (Check one box, complete information)
☐ Shelter (emergency, family, youth, domestic violence, etc.)
Name of Shelter:
Address:
Contact Phone #:
☐ Doubled-up (living with friends or relatives)
Name of Friend or Relative:
Address:
Contact Phone #:
☐ Hotel/Motel
Name:
Address:
Contact Phone #:
If the answer to Question #2 above is YES, please (√) the Supplies/Services Requested
School supplies or other related costs
Free breakfast and lunch
Free PE uniform (middle/high school)
Referral for counseling services for student
Assistance for referrals to shelters,
financial help, medical assistance, food, and clothing
Free summer school tuition
Referral Guide of Community Resources to include medical/vision
After-school tutoring
Free after-school care at participating schools (elementary), space limited
☐ Unsheltered (e.g. cars or other vehicle, parks, campgrounds, abandoned buildings, substandard housing, etc.)
Assistance w/college applications and financial aid (12th grade only)
Free graduation cap and gown (12th grade only)
Questions regarding this questionnaire may be directed to the District Office, Student Services department, at 707-778-4605. PCS Administrative Staff: Please retain a file at your school site that includes a complete set of the returned forms.
Loss of Housing Economic Hardship
Campus: Grade: Data Entry Complete:
Cuestionario de Residencia de Estudiantes Petaluma City Schools District
El propósito de este cuestionario es cumplir con la Ley de Asistencia para la Educación de las Personas sin Hogar McKinney- Vento. Las respuestas confidenciales a este cuestionario ayudarán a determinar si el estudiante podra ser elegible para recibir servicios.
1. Nombre del Estudiante: ____________________________________________________________ * Niño * Niña Nombre completo – use letra de molde
Fecha de Nacimiento: / / Edad: ___ Teléfono:
2. ¿Es su domicilio un arreglo temporario? _____ Sí _____No Si responde sí a esta pregunta, por favor complete el formulario.
3. ¿Es este arreglo de vivienda temporaria debido a la pérdida de su casa y/o dificultades económicas?
4. Nombre del Padre/Tutor Legal/Supervisor Adulto: ______________________________________________________ Nombre completo – use letra de molde
Relación con el Estudiante (por ej. abuelo, tío, tía, amigo): __________________________________________________
Domicilio: ______________________________________________________________________________________
Ciudad: _________________________________ Código Postal: _______ Teléfono: ______ ______________
Firma: _________________________________________________________________________________________
¿Dónde vive el estudiante actualmente? (Marque (√) un recuadro, llene toda la información)
Si la respuesta a la Pregunta #2 es sí, por favor marque (√) los materiales/servicios solicitados
Útiles escolares o costos relacionados ☐ En un Albergue (emergencia, familiar, para jóvenes, por violencia
doméstica, etc.) Desayuno y almuerzo gratis
Nombre del Albergue:
Domicilio:
No. de Teléfono de la Persona Contacto:
Guía de Recursos en la Comunidad (incluya vision y salud)
Recomendación para servicios de consejería para el alumno
☐ Compartiendo Vivienda (vive con amigos o familiares) Nombre del Amigo o del Familiar:
Ayuda para encontrar refugios, obtener ayuda financiera, asistencia médica, alimentos, y ropa
Domicilio:
No. de Teléfono de la Persona Contacto:
☐ Hotel/Motel
Matrícula gratis para la escuela de verano
Uniformes gratuitos para Educación Física (escuelas intermedias y secundarias)
Clases particulares después del horario escolar Nombre:
Domicilio: No. de Teléfono de la Persona Contacto:
Servicio de guardería gratis después del horario escolar en las escuelas participantes (solo para escuelas primarias), espacio limitado
☐ Sin Refugio (por ejemplo, en un automóvil, en el parque, en áreas para
campamentos, en edificios abandonados, en lugares no aptos para vivir, etc.)
Ayuda para llenar solicitudes para las universidades y la ayuda financiera (solo para alumnos de 12mo grado)
Toga y birrete gratuitos para la graduación (solo para alumnos de 12mo grado)
Preguntas acerca de este cuestionario pueden dirigirse a la Oficina del Distrito Escolar, el departamento de Servicios Estudiantiles, al 707-778-4605. PCS Personal de Administración: Please retain a file at your school site that includes a complete set of the returned forms.
Pérdida de Hogar Dificultades Económicas
Escuela: Grado: Fecha de ingreso de datos:
Gateway to College Academy Early College High School
CONSENT TO RELEASE CONFIDENTIAL INFORMATION and
REQUEST FOR CUMULATIVE FOLDER
I hereby authorize my current or former school, (Name of last high school)
and/or current or former school district to release confidential information about me
contained in my school records to Gateway to College Academy (GtC) and/or
Petaluma City Schools (PCS) and/or Santa Rosa Junior College (SRJC). Please send my
cumulative file folder as soon as possible to Gateway to College via standard mail to:
SRJC Petaluma
Atten: Gateway to College
680 Sonoma Mountain Parkway, Petaluma, CA 94954
Student Last Name First Name MI Date of Birth (month/day/year)
RELEASE TO:
❒ Santa Rosa Junior College (SRJC) ❒ Petaluma City Schools (PCS) ❒ Gateway to College Academy (GtC)
Information that will be released through authorization of signature below:
• Name, address and phone • Date of birth • Last high school attended and date • Disciplinary action
• Special Education information including IEP, assessment results, history
• Transcript of grades • Verification of attendance
Student Signature: Date:
Parent/Legal Guardian Signature, if under 18 years: Date:
Gateway to College Academy • SRJC Petaluma • 680 Sonoma Mountain Parkway, Kathleen Doyle Hall, Room 236, Petaluma, CA 94954 (707) 778-3630 • [email protected] • GtC.SantaRosa.edu
Gateway to College Academy Early College High School
CONSENTIMIENTO PARA LIBERAR INFORMACIÓN
CONFIDENCIAL y SOLICITUD DE CARPETA ACUMULATIVA
Por la presente autorizo a mi escuela actual o anterior, y / o distrito escolar actual o anterior a liberar
(Nombre de ultima secundaria)
información confidencial contenida sobre mí en mis registros escolares a Gateway to College Academy (GtC) y/o Petaluma City Schools (PCS) y/o Santa Rosa Junior College (SRJC). Por favor envíe mi carpeta de archivos acumulativos tan pronto como sea posible a Gateway to College por correo postal a:
SRJC Petaluma
Atten: Gateway to College
680 Sonoma Mountain Parkway, Petaluma, CA 94954
Apellido del Estudiante Nombre Fecha de nacimiento (mes/dia/año)
Liberar a:
❒ Santa Rosa Junior College (SRJC) ❒ Petaluma City Schools (PCS) ❒ Gateway to College Academy (GtC)
Información que será liberada mediante la autorización de la firma a continuación:
• Nombre, Dirección y Teléfono • Fecha de Nacimiento • Ultima secundaria asistida y Fecha • Acción disciplinaria
• Información de educación especial que incluye, plan educativo individual, resultados de evaluación, historial
• Calificaciones de transcripciones • Verificación de asistencia
Firma del Estudiante: Fecha:
Firma del Padre/Tutor, (Si es menor de 18 años) Fecha:
Gateway to College Academy • SRJC Petaluma • 680 Sonoma Mountain Parkway, Kathleen Doyle Hall, Room 236, Petaluma, CA 94954 (707) 778-3630 • [email protected] • GtC.SantaRosa.edu
Office of Public Relations, Santa Rosa Junior College, 1501 Mendocino Ave, Santa Rosa, CA 95401-4395, (707) 527-4266
Release Authorization to use Physical Likeness I hereby give permission to Santa Rosa Junior College (SRJC) to use my name, image, voice, likeness, information, photographs, video and sound recordings (collectively “Image”) for all purposes, including but not limited to: use in instruction, publications, media, advertising, or other promotional purposes by SRJC. I understand and agree that I will not receive any compensation for SRJC’s use of my Image.
If I am a student, I understand this Release is voluntary and my Image may be protected under the Family Educational Rights and Privacy Act (FERPA) as a student record, for which I now authorize this release to SRJC for the uses stated above. I shall have no right to title, or interest in the materials for which my Image may be used. I release SRJC from all liability related to the use of my Image. Any Image retained by SRJC will not be sold or given to another agency or organization for their commercial purposes.
I warrant that I have no legal restrictions on my ability to authorize the release of my Image. This agreement constitutes the sole, complete, and exclusive agreement between me and SRJC, which I have read, understand, and agree to. A copy of this Release is as good as the original.
FULL NAME (please print)
EVENT (or Class)
SIGNATURE
DATE
Signature of guardian (if under 18 years of age)* EMAIL or PHONE
FOR GUARDIANS OF MINORS *If the person named above is a minor (anyone under 18 years of age), parental or legal guardian consent is required for participation in the event in which an Image will be retained.
I, the above signed, as parent or legal guardian of the minor whose name appears above, consent to the foregoing conditions and warrant that I have the authority to give consent.
For Internal Use: Details re: Photographer, Project, Program, Notes, etc.
Oficina de Relaciones Públicas, Santa Rosa Junior College, 1501 Mendocino Ave, Santa Rosa, CA 95401-4395, (707) 527-4266
Autorización para Publicación y Uso de Apariencia Física Por este conducto le otorgo mi autorización al Santa Rosa Junior College (SRJC) para que use mi nombre, imagen, voz, apariencia, información, fotografías y grabaciones de sonido y de video (en conjunto “Imagen”) para cualquier propósito, incluyendo pero no limitado a: utilizarla en la enseñanza, publicación, medios, publicidad u otros propósitos promocionales del SRJC. Entiendo y estoy de acuerdo en que yo no recibiré ninguna compensación por el uso que haga el SRJC de mi Imagen.
Si yo soy estudiante, entiendo que esta Autorización es voluntaria y mi Imagen será protegida conforme al Acta de los Derechos Educativos Familiares y la Privacidad (FERPA), como si fuera un registro estudiantil, por lo cual le autorizo al SRJC su publicación para los usos que se especifican arriba. No tendré ningún derecho a título o interés en los materiales para los cuales mi Imagen fuera usada. Yo libero al SRJC de cualquier responsabilidad relacionada con el uso de mi Imagen. Cualquier Imagen retenida por el SRJC no será vendida o entregada a ninguna otra agencia u organización para propósitos comerciales.
Yo declaro que no existe ninguna restricción legal sobre mi capacidad de otorgar esta autorización para la publicación de mi Imagen. Este documento constituye el único, completo y exclusivo acuerdo entre mi persona y el SRJC, el cual he leído, entendido y estoy de acuerdo con él. Una copia de esta autorización es tan válida como el original.
NOMBRE COMPLETO (Por favor escríbalo)
EVENTO (o Clase)
FIRMA
FECHA
Firma del Padre o Tutor (si tiene menos de 18 años)* CORREO ELECTRONICO o TELEFONO
PARA LOS PADRES Y TUTORES DE MENORES *Si la persona que se menciona más arriba es menor de edad (cualquiera que tenga menos de 18 años), se necesita la autorización de los padres o tutor legal para poder participar en el evento que utilizará la Imagen.
Yo, quien firma arriba, como padre o tutor legal del menor cuyo nombre se menciona también arriba, autorizo las anteriores condiciones y declaro que tengo la autoridad para otorgar dicha autorización.
Para Uso Interno: Detalles de ref.: Fotógrafo, Proyecto, Programa, Notas, etc.
Gateway to College Academy • SRJC Petaluma • 680 Sonoma Mountain Parkway, Petaluma, CA 94954 • (707) 778-3630 • [email protected]
Gateway to College Academy Early College High School
CONSENT TO RELEASE & EXCHANGE CONFIDENTIAL INFORMATION _________________________________________________________________________________________________________________________________________ Student Last Name First Name MI Date of Birth (M/D/Y) E-Mail Santa Rosa Junior College (SRJC) and Petaluma City Schools shall follow all applicable state and federal laws, rules and regulations that apply to student records (See EC 76242 and EC 76243 below). The Family Educational Rights and Privacy Act of 1974 (FERPA) is a federal law that protects the privacy of student education records. The law applies to all schools that receive funds under an applicable program of the U.S. Department of Education. If a student is attending a postsecondary institution - at any age - the rights under FERPA have transferred to the student. All information contained in the college records which is personally identifiable to any student shall be kept confidential and not released except upon prior written consent of the student, or upon the lawful subpoena or other order of a court of competent jurisdiction. However, in a situation where a student is enrolled in both a high school and a postsecondary institution, the two schools may exchange information on that student. If the student is under 18 years of age, the parents still retain the rights under FERPA at the high school and may inspect and review any records sent by the postsecondary institution to the high school. I hereby authorize SRJC to release confidential information about me contained in my college school records. RELEASE TO:
Petaluma City Schools/Gateway to College Academy staff I also authorize Petaluma City Schools to release confidential information about me to SRJC. RELEASE TO:
SRJC/Gateway to College staff _________________________________________________________________________________________________________________________________________ Student Signature Date Information that will be released through authorization of signature:
• Any information in the Student Information System, including:
o Name, address, phone, e-mail o Transcript of grades o Student Education Plan o Completion of SSSP requirements
• Any information in the K-12 Cumulative Record and Aeries including: o Transcripts o Test scores and progress information o Disciplinary action
EC 76242 provides: A community college district may permit access to student records to any person for whom the student has executed written consent specifying the records to be released and identifying the party or class of parties to whom the records may be released. The recipient must be notified that the transmission of the information to others without the written consent of the student is prohibited. The consent notice shall be permanently kept with the record file.
EC 76243 provides: (a) A community college or community college district is not authorized to permit access to student records to any person without the written consent of the student or unless pursuant to judicial order, except that access may be permitted to the following: (4) Officials of other public or private schools or school systems, including local, county, or state correctional facilities where educational programs are provided, where the student seeks or intends to enroll, or is directed to enroll, subject to the rights of students as provided in Section 76225.
High School Dual Enrollment Request Form Office of Admissions, Records & Enrollment Development 1501 Mendocino Avenue, Santa Rosa, CA 95401 Phone: 707-527-4685 Fax: 707-527-4798
NOTE: All signatures are required or form will not be accepted or processed Part I – Student
Name __________________________________________________________ SRJC STUDENT ID#________________________ Last First Not high school ID
Date of Birth______/______/______ Phone__________________________ Email Address__________________________
I have read the High School Dual Enrollment (Special Admit) Expectations and Responsibilities on the back of this form and agree to abide by them. I also understand that I must submit an online SRJC application for every spring or summer/fall semester in order for this form to be processed (www.santarosa.edu/apply). Further, by signing this form I authorize Santa Rosa Junior College (SRJC) to release my educational records to my high school after each semester that I attend SRJC as a high school student.
Student’s Signature (required) ______________________________________ Date____________________________
Part II – Parent/Guardian
I am the parent or legal guardian of the above named student. I acknowledge that my child, as a college student, will be expected to adhere to all college rules of conduct, as well as the expectations and responsibilities detailed on the back of this form. I understand that in accordance with State and Federal law, I will not have the right to access my child’s records without his/her written consent or court order. I understand that SRJC reserves the right to deny admissions to specific courses. I give permission for emergency first aid treatment for my minor child/legal ward. I also give my permission for him/her to be treated by a nurse, physician and/or mental health counselor in the Student Health Center at SRJC.
Parent/Guardian Name (required) __________________________________ Signature: _____________________ Date: ________
Part III – Principal’s Recommendation & Certification
The above named student meets all the following criteria as defined by Education Code 48800.5 and 76001: Demonstrates adequate preparation in the discipline to be studied AND is able to benefit from college instruction.
For Summer Students ONLY:
• This recommendation does not exceed five percent of the students at the same grade level.• The student has exhausted all opportunities to enroll in an equivalent course, if any, at his or her school of attendance.
Recommended Courses (enrollment will be restricted to the courses listed below):
Semester Example: Fall 2016
Course Number/Title Example: ENGL 1A
Desired Section number Example: 3256
Units Example: 3
Counselor Initial
1
2
3
4
5
NOTE: students are permitted to enroll in another section of the same course if the section they have listed is closed. 9th grade students are advised to take up to 3 units; 10th grade students are advised to take up to 6 units; 11th and 12th grade students may take up to 11 units. All High School students may not take more than 6 units in the Summer term and no more than 11 units in the fall and spring semesters. High School students may NOT enroll in English 300 level courses regardless of assessment results.
Expected year of graduation _________ Name of School*_____________________________________ Phone ___________________
High School Counselor’s Signature (required) ____________________________________________ Date ____________________ Principal’s Signature or designee (required) ______________________________________________ Date ____________________
* If home schooled, a copy of the Private School Affidavit must accompany this form upon submission. ML 5/16/18
Vanessa Luna Shannon, Director/Head of School
High School Dual Enrollment (Special Admit) Expectations and Responsibilities
Special Admit Enrollment
• Section 48800 of the California Education Code allows the governing board of any school district to determine which students would benefit from advanced scholastic or vocational work. The intent of this section of the California Education Code is to provide educational enrichment opportunities for a limited number of eligible pupils, rather than reduce current course requirements of elementary and secondary schools.
• High School students may NOT enroll in English 300 level courses regardless of assessment results.
• Santa Rosa Junior College interprets “advanced scholastic” coursework as those courses designated as degree applicable (DA) in the SRJC Catalog https://admissions.santarosa.edu/college-catalog.
• Students who are 14 years of age or older or those who have completed the eighth grade or higher are eligible for dual enrollment as “special admit” students at SRJC.
• Santa Rosa Junior College reserves the right to exclude or limit enrollment of special admit students into impacted programs and other programs or courses based on health, safety, instructional methodology, faculty constraints, or legal requirements.
• Students enrolling in Kinesiology (PE) activity courses are subject to the 10% limit for each section. • All high school students must submit an online SRJC application every spring or summer/fall semester in order for
this form to be processed. This form must be submitted with all required signatures. Incomplete forms will not be processed.
• High School Dual Enrollment students may enroll online during priority 6 registration. Please submit your application online AND your High School Dual Enrollment Request form prior to your enrollment date. Mail, fax or bring in person your signed dual enrollment form, and proof of prerequisite completion (high school transcript) and complete the Prerequisite Equivalency form if enrolling in a course that has a prerequisite.
Student Responsibilities
• You may register for approved courses as recommended by your high school counselor and principal.
• All coursework taken at SRJC becomes a permanent part of your college academic history. Grades received or excessive drops have implications for future status involving financial assistance, athletic eligibility, academic standing, etc.
• File prerequisites and arrange for testing, if necessary. • You are responsible for reviewing and abiding by all academic and student policies in the Schedule of Classes and the College
Catalog.
• You are required to meet all academic deadlines. • High School Dual (Special Admit) students are exempt from enrollment fees if enrolled in less than 12 units. However dual
enrolled students must pay the student representation fee, the student health fee, and any course fees. Please see the Schedule of Classes for more information.
• SRJC is an adult academic learning environment and you are expected to behave accordingly. • By signing the front of this form, you agree that you are eligible to enroll as a High School Dual Enrollment (Special Admit)
student and will abide by all SRJC policies and procedures. Additionally, you agree that you have reviewed these expectations with your parent or guardian.
• Home schooled students must provide a copy of an Affidavit for Home Schooling, filed with the Department of Education, at the time of submitting this form.
Parent or Guardian Information
• Special Admit students are treated like every other college student. All college coursework is governed by the Family Educational Rights and Privacy Act (FERPA) which allows release of academic information, including grades, to the student only – regardless of age. Academic information is not released to parents or third parties without written consent of the student. Upon consent by the student, information is only released to the authorized party in person or in writing.
• SRJC Admissions and Records Office does not keep daily attendance records for students. Parents should not contact college offices or instructors with the expectation of accessing their student’s attendance or other information.
• Review your student’s High School Dual (Special Admit) Enrollment Form with him or her. Please be aware that all coursework at SRJC becomes a permanent record on the student’s academic college history; grades received or excessive drops have implications for future student status at the college, including financial assistance, athletic eligibility, etc.
• By entering a college environment, your son or daughter will be exposed to a diverse population in education programs designed for an adult learner that may involve sensitive topics that might be considered controversial or offensive in the secondary setting. SRJC will not change course content or curriculum to accommodate High School Dual Enrollment (Special Admit) students.
ML 5/16/18
California Department of Education, February 2017
Petaluma City Schools Application for Free and Reduced-Price Meals Complete one application per household. Please read the instructions on how to apply. Print clearly with a pen. You may also apply online at myschoolapps.com This institution is an equal opportunity provider. California Education Code Section 49557(a): Applications for free and reduced-price meals may be submitted at any time during a school day. Children participating in the federal National School Lunch Program will not be overtly identified by the use of special tokens, special tickets, special serving lines, separate entrances, separate dining areas, or by any other means.
STEP 1 – STUDENT INFORMATION Children in Foster Care and children who meet the definition of Homeless, Migrant, or Runaway are eligible for free meals.
Print the name of EACH STUDENT (First, Middle Initial, Last)
Enter school name and grade level
Enter student’s birthdate Check the applicable box if the student is foster, homeless, migrant, or runaway.
EXAMPLE: Joseph P Adams Lincoln Elementary 1st 12-15-2010 Foster Homeless Migrant Runaway
STEP 2 – ASSISTANCE PROGRAMS: CalFresh, CalWORKs, or FDPIR Do ANY household members (child or adult) currently participate in CalFresh, CalWORKs or FDPIR? If NO, skip STEP 2 and continue to STEP 3.
If YES, check the applicable program box, enter one case number, skip STEP 3, and continue to STEP 4.
Select Program Type:
CalFresh CalWORKs FDPIR
Enter Case Number:
STEP 3 – REPORT INCOME FOR ALL HOUSEHOLD MEMBERS (Skip this step if you answered ‘YES’ in STEP 2)
A. STUDENT INCOME: Sometimes students in the household earn income. Enter the TOTAL GROSS income (before deductions) in whole dollars earned by all students listed in STEP 1. Enter the appropriate pay period in the “How
Often” box: W = Weekly, 2W = Biweekly, 2M = Twice a Month, M = Monthly, Y = Yearly
Total Student Income How Often
$
B. ALL OTHER HOUSEHOLD MEMBERS (including yourself): List ALL household members not listed in STEP 1, even if they do not receive income. For each household member, report the TOTAL GROSS income (before deductions) in whole dollars for each source. If the household member does not receive income from any sources, write “0”. If you enter “0” or leave any fields blank, you are certifying (promising) that there is no income to report. Enter the appropriate pay period in the “How Often” box: W = Weekly, 2W = Biweekly, 2M = Twice a Month, M = Monthly, Y = Yearly
Print the name of ALL OTHER Household Members (First and Last)
Earnings from Work How Often
Public Assistance/SSI/ Child Support/Alimony
How Often
Pensions/Retirement/All Other Income
How Often
$ $ $
$ $ $
$ $ $
$ $ $
C. Total Household Members (Children and Adults)
D. Enter the last four digits of Social Security number (SSN) fromthe Primary Wage Earner or Other Adult Household Member
Check the box if
NO SSN
DO NOT COMPLETE. SCHOOL USE ONLY
How Often? Weekly Bi-Weekly Twice a Month Monthly Yearly Annual Income Conversion: Weekly x52, Biweekly x26, Twice a Month x24, Monthly x12
Total Household Income
$
Total Household Size Eligibility Status: Free Reduced-price Paid (Denied) Categorical
Verified as: Homeless Migrant Runaway Error Prone
Determining Official’s Signature: Date:
Confirming Official’s Signature: Date:
Verifying Official’s Signature: Date:
STEP 4 – CONTACT INFORMATION & ADULT SIGNATURE
Certification: I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of federal funds, and that school officials may verify (check) the information. I am aware that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted under applicable state and federal laws.
Signature of adult completing this application:
Print Name:
Date: Phone Number:
Mailing Address:
City: State: Zip:
E-mail:
OPTIONAL – CHILDREN’S ETHNIC AND RACIAL IDENTITIES We are required to ask for information about your children’s race and ethnicity. This information is important and helps to make sure we are fully serving our community. Responding to this section is optional and does not affect your children’s eligibility for free or reduced-price meals.
Ethnicity (check one):
Hispanic or Latino Not Hispanic or Latino
Race (check one or more):
American Indian or Alaskan Native Asian Black or African American
Native Hawaiian or other Pacific Islander White
PETALUMA CITY SCHOOLS EP ☐
2018-2019 SOLICITUD PARA COMIDAS GRATUITAS/PRECIO REDUCIDO Favor de completar solamente UNA solicitud por hogar. Un "miembro de la familia" es alguien que vive con usted y comparte los ingresos y los gastos, aunque no sea un familiar. Por favor devuelva esta solicitud completa a la escuela de su hijo(a) o a la oficina de distrito de Petaluma. La Sección 49557(a) del Código de Educación de California establece que: ”Las solicitudes para las Comidas Gratuitas y a Precios Reducidos tienen que ser entregadas durante cualquier hora durante el día escolar. Los niños(as) que participen en el Programa Nacional de Comidas Escolares no pueden ser abiertamente identificados(as) mediante el uso de fichas o boletos especiales, filas especiales donde se les sirva la comida, entradas o cafeterías separadas o mediante ningún otro modo.” SECCIÓN A: Enliste los nombres de todos los miembros del hogar que son los bebés, niños y estudiantes hasta el grado 12.
OPCIONAL: Consentimiento del padre o tutor para el intercambio de información para los beneficios de las estampillas de comida-De conformidad con el Código de Educación de California 49558 (d)
Nino en adopcion temporal
Sin hogar, Migrante, Escapado, Head Start
Total de adultos y ninos en el hogar:
Apellido Nombre Escuela Grado Fecha de Nacimento
Ingreso del nino si recibe
Con su consentimiento, esta solicitud o la información que contiene, sólo será compartida con su agencia local de estampillas de comida y sólo para fines directamente relacionados con la inscripción de su familia en el programa de estampillas de comida. El consentimiento debe administrarse únicamente por el padre o tutor del estudiante. En los hogares con múltiples familias, el padre o tutor de cada estudiante debe firmar por su propio hijo (s). Negarse a dar su consentimiento no afectará la elegibilidad de su hijo para el programa de comidas.
Marque todo lo que corresponda
☐ ☐ Marque esta casilla si usted es el padre o tutor de cada estudiante que aparece en el seccion de A para dar su consentimiento para compartir esta aplicación como se ha indicado anteriormente. Escriba abajo el nombre de padre/madre, firme y escriba la fecha de hoy.
☐ ☐ Nombre del estudiante
Nombre de Padre/Madre
Firma del Padre/Madre Fecha
☐ ☐
☐ ☐
☐ ☐ SECCIÓN E: Identidades Étnicas y Raciales de los(as) Niños(as) (opcional):
SECCIÓN B: ¿Algún miembro de la familia (incluyéndote a ti) recibe CalFresh (estampillas de comida), CalWORKS, Kin-GAP, o FDPIR. En dado caso, escriba el # de caso en el espacio de abajo:
1. Indique una o más identidades raciales: ☐ Indígena americano o nativo de Alaska ☐ Africano Americano ☐ Asiático ☐ Hawaiano nativo u otra clasificación de las Islas Pacificas ☐ Blanco 2. Indique una identidad étnica: ☐ Origen latino o hispano ☐ Origen NO latino o hispano
SECCIÓN C: Reporte los ingresos de TODOS los miembros adultos del hogar. No complete esta sección si un número de caso de CalFresh/CalWORKS/Kin-GAP/FDPIR es proporcionado en la sección B Enliste todos los miembros adultos de hogar e indique la cantidad mensual y la fuente de los ingresos mensuales brutos que cada miembro del hogar recibió el mes pasado. Incluya a los adultos con cero ($0) ingresos. Si usted indica $0 o deja en blanco los espacios, usted está certificando que no hay ningún ingreso que reportar.
APELLIDO PATERNO PRIMER NOMBRE SUELDOS DE TRABAJO
(ANTES DE LAS DEDUCCIONES) INCLUYA TODOS LOS TRABAJOS
INGRESOS DE PENSIÓN,JUBILACIÓN,
SEGURIDAD SOCIAL
BENEFICIOS DE WELFARE, MANUTENCIÓN DE HIJO(S),
PARA NIÑOS O ASISTENCIA DE DIVORCIO
CUALQUIER OTRO INGRESO MENSUAL
SECCIÓN D: Firma (requerida) e información de contacto: "Certifico que toda la información proporcionada es verdadera y correcta y que todos los ingresos han sido reportados. Entiendo que esta información se proporciona en relación con el recibo de fondos federales, y que los funcionarios escolares pueden verificar la información. Estoy consciente de que si doy deliberadamente información falsa, mis hijos pueden perder los beneficios de comida, y podría ser procesado bajo las leyes estatales y federales.”
Firma de miembro adulto del hogar quien llena esta solicitud Escriba los últimos 4 dígitos de su número de seguro social XXX – XX -______ ______ ______ _____ ☐ Yo no tengo un numero de seguro social
Fetcha Telefono
Escriba el nombre del aduto que firma esta solicitud Nombre Domicilio Ciudad Codigo Postal
*Usted o sushijos no tienen que ser ciudadanos estadounidenses para calificar para comidas gratis o a precio reducido.
