los angeles unified school district early childhood

This document should be included in the family file.

Child Name/s: ____________________________________________ Date of Birth: ____________________

Welcome to our Early Education Center. In order to enroll your child, please have available and completed by your appointment date, the documents & information checked below:

(LAUSD SECTION)

Received COMPLETE

Scanned to EESIS

◊ Birth Certificate or Baptismal Record of ALL children under 18 years of age in the family. ◊ Immunization records for child being enrolled (California Immunization Requirements for

Child Care 01/19)

◊ Proof of income – One full month’s worth of check stubs for the prior month for each parent employed. (If paid weekly, submit the last 4 consecutive check stubs, if paid bi-weekly, submit the last 2 consecutive check stubs.)

◊ Verification of TANF or other cash assistance (copy of most recent check – prior month, Notice of Action or Cash Issuance Receipt)

◊ Verification of California Residency (CA ID, CA Driver’s License, Current Utility Bill, Rent Receipt, Lease Agreement, etc.)

ATTACHMENTS ◊ Home Language Survey Student Enrolment Form Ref 5259.1 08/19 ◊ Health History Card (white, to be completed by the parent/guardian) 07/86

◊ Physical Exam – Physician’s Report (LIC 701 form to be completed by the doctor. Must be within the last 12 months and include screening of TB risk) 08/08

◊ Verification of Employment and Salary – Form 83.56 04/19 ◊ Self-Certification of Income (if applicable) 04/19 ◊ Verification of Training – Form EESD 9605 01/15 (Progress Report at Recertification Time)

Request for study time must be written and provided by parent

◊ Statement of Incapacity – CD 9606 06/08 ◊ Child Protective Services Referral Form 83.66 06/19 ◊ Seeking Employment Agreement 04/18 ◊ Los Angeles Unified School District Parent Handbook – Forms completed & signed SY 20-21

◊ Student Emergency Information Form (At least 3 names, addresses and telephone numbers of persons, 18 years or older, authorized to pick up your child in case of emergency or illness) Make sure that the name matches what appears on Driver License or I.D.s 01/14

◊ If Applicable: Verification of Other Care Providers – Form 84.26 03/19 ◊ Student Housing Questionnaire 07/19; Migrant Education Program Questionnaire 10/18 & Safe

Gun Storage Acknowledgement Form 09/19

◊ Other : _________________________________________________________________

Your appointment date is _______________________________________ Time: _________ AM / PM

You must bring all requested documents on that date, and be ready to stay 30 minutes, so that we can verify the information and give you the policies and procedures of this program. If you do not show up to your

appointment, we will proceed to enroll the next family on our waiting list.


PARENT ENROLLMENT PACKET CHECKLIST

LOS ANGELES UNIFIED SCHOOL DISTRICT Early Childhood Education

EEC ______________________________________ Phone: _____________ E-mail: _________________


____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


FOR LAUSD USE ONLY CASE NOTES FOR LAUSD USE ONLY

EESIS ID# _____________ Parent/s Name________________________ Room # ________

Child Name ________________________ Birthday ____________ Program CCTR CSPP

Has the family previously been enrolled in a LAUSD ECED Program? YES NO

CONTRACT SIGNATURES COMPLETE

SCANNED TO EESIS

Notice of Action (CD 7617) – with Parent initial or receipt of certified mail and Principalsignature

CD 9600 page 1 & 2 – with proper box checked, dated, initialed (Single Parent) and Signedby Parent and Principal


EEC ______________________________________ Phone: _____________ E-mail: _________________

LOS ANGELES UNIFIED SCHOOL DISTRICT

REFERENCE GUIDE

Attachment A

REF-5259.1 Student Health and Human Services

August 16, 2019

STUDENT ENROLLMENT FORM

Student Name: Date of Birth (Month/Day/Year): / /

C. HOME LANGUAGE AND ETHNICITY INFORMATIONHome Language of the Student

Which language did your child learn when he/she/they first began to talk?

Which language does your child most frequently use at home?

Which language do you (the parents or guardians) most frequently use when speaking to your child?

Which language is most often spoken by adults in the home? (parents, guardians, grandparents, or any other adults)

Has this student received any formal English language instruction? ☐ Yes ☐ No

Student’s Primary Ethnicity

Is the student’s ethnicity Hispanic or Latino? ☐ Yes ☐ No

Student’s Primary Race (Check One)

☐ African American orBlack

☐ American Indian or Alaska Native ☐ White

Asian: ☐ Asian Indian ☐ Cambodian ☐ Chinese ☐ Filipino ☐ Hmong

☐ Vietnamese ☐ Other Asian:

☐ Japanese ☐ Korean ☐ Laotian

Pacific Islander: ☐ Guamanian ☐ Native Hawaiian ☐ Samoan ☐ Tahitian☐ Other Pacific Islander:

☐ Decline to State

Student’s Additional Race (Optional)

☐ African American orBlack

☐ American Indian or Alaska Native ☐ White

Asian: ☐ Asian Indian ☐ Cambodian ☐ Chinese ☐ Filipino ☐ Hmong

☐ Vietnamese ☐ Other Asian:

☐ Japanese ☐ Korean ☐ Laotian

Pacific Islander: ☐ Guamanian ☐ Native Hawaiian ☐ Samoan ☐ Tahitian

☐ Other Pacific Islander:

☐ Decline to State

SIGNATURE I verify that the information contained in this document is true and correct to the best of my knowledge.

XSignature Date

Printed Name Relationship to Student

LOSANGELESUNIFIEDSCHOOLDISTRICT–PERMANENTHEALTHHISTORY

StudentsName_______________________________________Sex:M___F___BirthDate_________________LAST FIRST MIDDLE MONTHDAYYEAR

LastSchoolorChildren’sCenterAttended:_______________________________Name

Location__________________________________________________________City&State

PresentGrade________SPECIALCLASSORSCHOOL___________________________________________

HealthCareProvider/Physician______________________________Dateoflatephysicalexamination____________________________FamilyDentist____________________________________________Dateoflastdentalexamination______________________________

CHILD’SILLNESS(pastorpresent)pleasecheck(√):FAMILY:Father

Livingwithchild(Names) HEALTH

ChickenpoxYes NO

FrequentsorethroatYes NO

Mother Meningitis Earaches/infectionsStepparent Mumps HearinglossOthers Rubella(3daymeasles) Speechproblem

BrothersHowManyOlder HowManyYounger HEALTH Rubeola(10-daymeasles) Eyeproblem

WhoopingCough Wearsglasses/contactsSisters PositiveTBSkinTest Heartcondition/murmur

Haschildeverbeenhospitalizedovernight?Yes___No___Nameofhospital_____________________City______________State_________Dates in hospital ____________________________________________________Reasonsforhospitalization_____________________________________________________________________________________________________________Ischildonmedication?Yes____No____Name of medicine __________________________________________________Amount_____________________Frequency___________________________Are physical activities limited? Yes ______ No______Ifyes,reasonforlimitation:___________________________________________

Bronchitis HighBloodPressurePneumonia KidneyProblemAsthma DiabetesHivesorEczema BlooddiseaseDrugorOtherAllergy MenstrualproblemHeadInjury HerniaSeizures/Unconscious Parasites(worms)Otherseriousaccidentsorillness(describe)______________________

BIRTHHISTORYMOTHER’SPREGNANCY:Infections

YES NODEVELOPMENTHISTORYAtwhatagedidyourchild:Sitalone_________________ Crawl_________________________Standalone______________ Walk_________________________Saywords________________ Usesentences_________________Toilettrain_______________ Feedself______________________

BleedingHighBloodPressureToxemiaDiabetesOtherComplicationsofPregnancy PLEASECHECK()DOESYOURCHILD:

9-MonthPregnancyEnjoylearning

YES NOBitenails

YES NO

TypeofDelivery Likeschool Suckthumb

Child’sbirthweight__________

child’sbirthcondition(check)good_______poor________Ifpoor,describe:_____________________________________________________________________________________________________________________

Likeotherchildren WetbedEatwell SeemshyDrinkmilk FallfrequentlyEatBreakfast HavetempertantrumsSleepwell SeemoveractiveFollowdirections

ILLNESSDURINGFIRST2WEEKSOFLIFE:

Troublebreathing

YES NOWhattimedoesyourchildgotobed?___________________________

Doyouhaveanyquestionsorconcernsaboutyourchild’shealth?Pleaselist. _________________________________________________Seizures

Cyanosis(bluecolor)Jaundice(yellowcolor)Feedingproblems

______________________________________________________Date Parent/GuardianSignature_______ _______________________________________________Date Historytakenby(Name)

_______________________________________________Title

_______________________________________________NameofSchool

AnemiaBirthdefect

RequiredincubatorWenthomewithmother

FORM34-EH-677/86STK.NO.815292 LOSANGELESUNFIEDSCHOOLDISTRICTC.C.9661215292 StudentHealthand Human ServicesDivision

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VERIFICATION OF EMPLOYMENT

PARENT SECTION: California state law (5 CCR 18084) requires that families receiving LAUSD early childhood education services document total income. I agree to provide check stubs or other record of wages. I authorize my employer to release the following information to the early childhood education program named above. I also authorize the early childhood education program to contact my employer to verify any information indicated on this form.

_____________________________ ____________________________ _________________ Parent / Employee Name Signature of Parent / Employee Date

EMPLOYER SECTION: Please complete and return to the location shown above.

Employer: _______________________________________________ Phone: _____________________

Address: ________________________________________________ Business Hours: ______________

Employee Position / Department: ____________________________ Date of Hire: ________________

How is the employee paid? Weekly Bi‐Weekly Bi‐Monthly Every 4 Weeks Monthly

Paid by: Cash Check GROSS Earnings Per Pay Period: _____________ Possibility of?

Number of Hours Employed Per Week____________ Hourly Rate $ ___________ Tips Overtime

DAYS AND HOURS OF EMPLOYMENT

HOURS MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY

FROM:

TO:

If working a variable schedule, please check one: Days vary Hours vary Days and hours vary Please explain: ____________________________________________________________________________

_____________________________ _______________________________ ________________ Employer Name/Title Signature of Employer Representative Date

LAUSD SECTION: Travel time requested 30 minutes 60 minutes

Student’s Name: ______________________________________________ Family ID: ___________________

Means of verification: _____________________________________________________________________

Notes: __________________________________________________________________________________

Verified By: ______________________________________ Date: ______________________________

Form 83.56 Rev. 4/2019


PARENT SECTION: Name of parent: ____ Family ID: _____________________

Child: _________________________

1. Self‐certification of employment income is requested for the following reason:

The early education program requested that I complete this form because my employer hasrefused or failed to provide my employment information.

I have asked that my employer not be contacted to verify my employment because thatcontact could put my employment at risk.

I do not have pay stubs, receipts or other documentation of employment. Other

EMPLOYER

Date hired:

Type of work performed:

Rate of pay: ($___ per ____)

$

How often paid? (Weekly, monthly, etc.)

Paid by: (Cash, check)

Work day hours: (___AM ‐ ___ PM)

Days worked each week: (Mon. ‐ Fri.)

Total paid for the month: $

2. Self‐certification of non‐employment income when no documentation is possible:

What type?

How much?

How often? Why?

I declare under penalty of perjury that the above information is true and correct to the best of my knowledge. I understand that I may be asked to document my activities each week.

_________________________________________ _____________________ Parent Signature Date

LAUSD SECTION: Notes: __________________________________________________________________________

Assessed By: _____________________________________ Date: _______________________

Rev. 4/2019

LOS ANGELES UNIFIED SCHOOL DISTRICT EARLY CHILDHOOD EDUCATION

SELF‐CERTIFICATION OF INCOME

Training Verification –Parent or Caretaker Attending School or Receiving Training

Date

Agency Name, Street Address, City, ZIP Code, and Phone Number

Parent Name, Street Address, City, ZIP Code, and Phone Number Signature_______________________________________

Training/Education Information Profession/Vocational Goal (Not Academic Goal) (E.g. Vocational Goal is to become a teacher.) (E.g. Academic Goal is to obtain Degree or Certificate) Name of School or Organization where training/education is received

Phone Number

Street Address, City, Zip Code

Anticipated Completion Date for Training/Education

Date this Term Began Date this Term Ends Complete One of the Following

Attached is the parent’s course printout form from the training institute. or

Below is the parent’s class schedule with the signature and stamp of the Registrar’s office. Class Schedule (if applicable)

Day Time Room # Course Name Units Signature and Stamp of Registrar of School/Organization Date of Signature and Seal

California Department of Education Early Education and Support Division

Form EESD-9605 (January 2015)

CALIFORNIA DEPARTMENT OF EDUCATION NOTE: When applicable, this form is to be completed Early Education and Support Division and used with form, CD-9600. Form CD-9606, (Rev. June 2008)

STATEMENT OF PARENTAL INCAPACITY Please print or type information.

PART I – To be completed by the authorized agency representative and the incapacitated parent. By signing this form and for the purpose of verifying my incapacity to care for the family’s children as it relates to the family’s eligibility for subsidized child care and development services, I authorize and request the health professional named in Part II to release the information requested to the agency identified below. I further authorize the health professional to discuss this Statement of Incapacity with the agency in order for the agency to verify, clarify, or complete it. I understand the health professional may also require that I complete his or her own release form prior to providing the information requested below. NAME OF PARENT/CARETAKER SIGNATURE OF PARENT/CARETAKER DATE

FIRST NAME AND AGE OF THE CHILD(REN) FOR WHOM FINANCIAL ASSISTANCE FOR CHILD CARE IS BEING REQUESTED:

1. 2. 3. 4.

AGENCY AUTHORIZED AGENCY REPRESENTATIVE (Please print.) TELEPHONE NUMBER

( ) ADDRESS CITY ZIP CODE

PART II – To be completed by the licensed health professional. For the family to be eligible to receive child care and development services under the category of incapacity, the California law requires verification, at least annually, of the physical or mental incapacity of the parent or caretaker that renders the person incapable of caring for or supervising the family’s child(ren) without assistance. (See California Code of Regulations, Title 5, §18088.) Your cooperation in completing and returning this form to the agency listed above within 15 days of receipt is requested.

PATIENT ___________________ HAS

a physical condition or

a mental health condition

that prevents him or her from providing care or supervision for the child(ren) listed above for at least part of the day.

Please indicate the time in a day and the days of the week, not to exceed 50 hours in a week, that the parent is unable to care for or supervise the child(ren).

Child care

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Start Time: am/

pm am/ pm

am/ pm

am/ pm

am/ pm

am/ pm

am/ pm

End Time: am/

pm am/ pm

am/ pm

am/ pm

am/ pm

am/ pm

am/ pm

PROBABLY DATES OF INCAPACITY

From: To:

If the time of day cannot be easily identified in consultation with the patient, please identify the number of

hours and days of the week [M, T, W, T, F, S, S] that services are needed.

If the parent has a physical/medical condition, please identify the extent to which the parent is incapable of providing care and supervision.

Please sign and submit this form to the agency listed in Part I within 15 days of receipt of this form. NAME OF LICENSED HEALTH PROFESSIONAL LICENSE TYPE LICENSE NUMBER

SIGNATURE OF LICENSED HEALTH PROFESSIONAL DATE TELEPHONE NUMBER

( ) MEDICAL GROUP OR ORGANIZATION WITH WHICH THE PROFESSIONAL IS AFFILIATED, IF ANY

ADDRESS CITY STATE ZIP CODE

Center Name : _ ___________________________________________ Email: ________________________

Address:, _______________________________ Phone: (___)-__________ Fax: (___)-_____________

CHILD SECTION Child(ren) being referred for Early Childhood Education Services:

Child Name: _____________________________________ Child Name: __________________________________ Birthdate: ________________ Birthdate: ________________

Living with: Parent / Guardian Name: _______________________________________ Is the child in an out‐of‐home placement? Yes No If yes, child is living with:

Relative ‐ relationship: ____________________ Foster Parent Other (describe) _________________

Probable duration of services*: __________________________ Hours care needed: _____________________ *Not to exceed 12 months for child protective services or child at risk of abuse, neglect or exploitation

DCFS REFERRAL SECTION For use by Los Angeles County Department of Children and Family Services only

I certify that the child(ren) is receiving child protective services and child care and development services are a necessarycomponent of the child protective services plan.

I also certify that it is necessary to waive any family fee and income information will not be required from the family. Feeexemptions cannot be granted beyond 12 months regardless of whether the child continues to receive child protectiveservices. The 12 month time limit is a cumulative total.

If Early Childhood Education services have continued for 12 months, I certify that the family continues to receive childprotective services and that child care and development services are part of the case plan.

DCFS Case Number: ______________________________

_________________________________ _______________________________ _______________ DCFS Representative Name / Title Signature Date

Address: ______________________________ Phone: _________________ Email: ___________________________

AT RISK REFERRAL SECTION For use by all organizations/entities other than DCFS I certify that I am a legally qualified professional from a legal, medical, social service agency, or emergency shelter and that

child care services are required to reduce or eliminate the risk of abuse, neglect or exploitation of the child(ren). I understandthat these services are limited to 12 months.

I also certify that it is it is necessary to waive any family fee for the 12 months and income information will not be requiredfrom the family.

Referring Agency: _________________________________ Case Number: __________________

____________________________________ _______________________________ ________________ Referring Professional Name / Title Signature Date

Address: ______________________________ Phone: ______________ Email: ___________________________

Form 83.66 (Rev. 06/19)

LOS ANGELES UNIFIED SCHOOL DISTRICT EARLY CHILDHOOD EDUCATION DIVISION

CHILD PROTECTIVE SERVICES / AT RISK REFERRAL

LAUSD SECTION: Name of parent: Family ID: ____________

Effective date of seeking employment:

California state law (5CCR 18086.5) requires that eligibility for seeking employment is limited to 12 months.

You will use the maximum number of days allowable on _______________________. If by that date you have not secured employment, child development services to your family may be terminated.

PARENT SECTION:

1. Please indicate the activities you will use to actively seek employment:

Look for jobs in the newspaper Make phone calls

Use the internet Write and send resumes

Apply for in‐person interviews Apply to an employment agency

Visit college placement center Go door‐to‐door Go to the Employment Development Department (Unemployment Office)

Other

2. Please indicate if you would like:

A set schedule (same hours each day, not to exceed 30 hours each week)

A variable schedule (varied hours based upon seeking employment activities, not to exceed 30 hours each week)

If you would like a fixed schedule, indicate the hours and days of the week you will use to actively seek employment:

HOURS MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

FROM:

TO:

I declare under penalty of perjury that I am seeking employment and that the above information is true and correct to the best of my knowledge. I understand that I may be asked to document my activities each week. I will notify the center immediately if there is any change in my employment status.

_______________________________________________ _____________________ Parent Signature Date

BUL‐4363.0 Rev. 04/2018

LOS ANGELES UNIFIED SCHOOL DISTRICT EARLY CHILDHOOD EDUCATION

SEEKING EMPLOYMENT AGREEMENT

Los Angeles Unified School DistrictParent/Guardian Publicity Authorization and Release

Dear Parent/Guardian:

The Los Angeles Unified School District requests your permission to reproduce through printed, audio, visual, or electronic meansactivities in which your pupil has participated in his/her education program. Your authorization will enable us to use speciallyprepared materials to (1) train teachers and/or (2) increase public awareness and promote continuation and improvement ofeducation programs through the use of mass media, displays, brochures, websites, etc.1. Name of Pupil (please print) 2. Birthdate (please print)

3. Name of Parent (please print)

a. I, as a parent of guardian, of the above named pupil fully authorize and grant the Los Angeles Unified School District and itsauthorized representatives, the right to print, photograph, record, and edit as desired, the biographical information, name,image, likeness, and/or voice of the above named pupil on audio, video, film, slide, or any other electronic and printed formats,currently developed, (known as “Recordings”), for the purposes stated or related to the above.

b. I understand and agree that use of such Recordings will be without any compensation to the pupil or the pupil’s parent orguardian.

c. I understand and agree that the Los Angeles Unified School District and/or its authorized representatives shall have theexclusive right, title, and interest, including copyright, in the Recordings.

d. I understand and agree that the Los Angeles Unified School District and/or its authorized representatives shall have theunlimited right to use the Recordings for any purposes stated or related to the above.

e. I hereby release and hold harmless the Los Angeles Unified School District and its authorized representatives from any and allactions, claims, damages, costs, or expenses, including attorney’s fees, brought by the pupil and/or parent or guardian whichrelate to or arise out of any use of these Recordings as specified above.

__________________________________________________________________________________________________________My signature shows that I have read and understand the release and I agree to accept its provisions.

4. Signature of Parent/Guardian 5. Date Signed

6. Address (Number, Street, Apartment Number)

7. City 8. State 9. Zip Code

10. Telephone

Granting of permission is voluntary. Please return completed form to school.11. Principal Approved as to form by the

Office of the General Counsel.

This form shall not be amended without12. School written approval of both the Office of the

General Counsel and the Office ofCommunications/Public Information

LOS ANGELES UNIFIED SCHOOL DISTRICT STUDENT EMERGENCY INFORM ATION FORM

Parent Information: Please fill out completely and sign where indicated. In a major emergency, it is school district policy to retain students at school for their safety. This form will be used by the school staff when students are released to go home. Please complete electronically or print clearly and return completed form to school.

STUDENT’S LAST NAME FIRST NAME M.I. ST

UD

EN

T’S

LAS

T N

AM

E

BIRTH DATE GRADE HOME LANGUAGE

MALE FEMALE STUDENT’S HOME ADDRESS -- NUMBER STREET APT # CITY ZIP CODE

MAILING ADDRESS -- NUMBER (IF DIFFERENT FROM ABOVE)

STREET APT # CITY ZIP CODE

PARENT’S / LEGAL GUARDIAN’S LAST NAME FIRST NAME RELATIONSHIP TO STUDENT LIVES WITH?

Yes No

WORK ADDRESS -- NUMBER STREET CITY ZIP CODE

CONTACT NUMBERS Indicate which phone to call for each message type:* EMAIL ADDRESS:

HOME EMERGENCY Home Cell Work CELL ATTENDANCE Home Cell Work

WORK GENERAL INFO Home Cell Work

TEXT I authorize receiving text messages and understand that I am responsible for all text related charges.

PARENT’S / LEGAL GUARDIAN’S LAST NAME FIRST NAME RELATIONSHIP TO STUDENT LIVES WITH?

Yes No

WORK ADDRESS -- NUMBER STREET CITY ZIP CODE

CONTACT NUMBERS Indicate which phone to call for each message type:* EMAIL ADDRESS:

HOME EMERGENCY Home Cell Work CELL ATTENDANCE Home Cell Work

WORK GENERAL INFO Home Cell Work

TEXT I authorize receiving text messages and understand that I am responsible for all text related charges.

To the principal: In case you are unable to reach me during any emergency, you are authorized to contact and, if necessary, release my child to any of the following:

NAME RELATIONSHIP HOME PHONE CELL PHONE WORK PHONE FIR

ST

NA

ME

NAME RELATIONSHIP HOME PHONE CELL PHONE WORK PHONE

NAME RELATIONSHIP HOME PHONE CELL PHONE WORK PHONE

List any other family members attending this school:

LAST NAME FIRST NAME HOME ROOM GRADE RELATIONSHIP LAST NAME FIRST NAME HOME ROOM GRADE RELATIONSHIP MILITARY CONNECTED FAMILY: In efforts to provide

resources and support to military connected students and their families, please respond to the following:

Immediate family member in the military (Active Duty, Guard, Reserve, or Veteran): YES NO Relationship to Student: ______________________

Currently Deployed: YES NO Military Branch: ____________________________________________ Status: Active Duty; Guard; Reserve; Veteran; Deceased

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT

The undersigned, as parent/legal guardian of, a minor,

(Print name of the student here)

hereby authorizes the principal or designee, into whose care the student has been entrusted, to consent to any X-ray examination, anesthetic, medical or surgical diagnosis, treatment, and/or hospital care to be rendered to the student upon the advice of any licensed physician and/or dentist. It is understood that this authorization is given in advance o f any required diagnosis, treatment, or hospital care and provides authority and power to the Los Angeles Unified School District (“District”) to give specific consent to any and all such diagnosis, treatment, or hospital care which a licensed physician or dentist may deem necessary. This authorization is given in accordance with Section 49407 of the California Education Code, and shall remain effective until revoked in writing and delivered to the District. I understand that the District, its officers and its employees assume no liability of any nature in relation to the transportat ion of the student. I further understand that all costs of paramedic transportation, hospitalization, and any examination, X-ray, or treatment provided in relation to this authorization shall be my sole responsibility as the student’s parent/guardian .

HEALTH ALERTS -- List any medical condition which restricts physical activity or requires special attention. Include conditions such as asthma and allergies such as peanut and bee stings. If none, please indicate “none”.

DOES THE STUDENT HAVE HEALTH INSURANCE? (Check One) YES NO* If “Yes”: Private Health Insurance Medi-Cal Healthy Families

MEDI-CAL / HEALTHY FAMILIES ID Number: MID

DLE

INIT

IAL

1. PRIVATE HEALTH INSURANCE NAME GROUP NO. 2. PRIVATE HEALTH INSURANCE NAME (If covered under more than one plan)

GROUP NO.

NAME OF DOCTOR / MEDICAL OFFICE PHONE NUMBER OF DOCTOR / MEDICAL OFFICE

*If the student currently does not have health insurance, information on free or low-cost health care programs is available by calling the District’s toll-free HELPLINE 1(866)742-2273.

MY CHILD IS ALLERGIC TO THE FOLLOWING MEDICATIONS: MY CHILD CURRENTLY TAKES THE FOLLOWING MEDICATIONS:

I CERTIFY THAT I HAVE READ AND UNDERSTOOD THIS FORM AND DO HEREBY GIVE MY AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT, AND THAT ALL OF THE INFORMATION I HAVE PROVIDED ON THIS FORM IS TRUE AND CORRECT.

X DATE SIGNATURE OF: (CHECK ONE) PARENT LEGAL GUARDIAN CAREGIVER (AFFIDAVIT)

* Selected telephone number must be a direct dial number (no extensions). Revised January 2014

angie.vasquez

Typewritten Text

angie.vasquez

Typewritten Text

angie.vasquez

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STUDENT EMERGENCY INFORMATION FORM

To the principal: In case you are unable to reach me during any emergency, you authorized to contact and, if necessary, release my child to any of the following:

# Name Relationship Home Phone Cell Phone Work Phone

1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17 18 19 20

I CERTIFY THAT I HAVE READ AND UNDERSTOOD THIS FORM AND DO HERREBY GIVE MY AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT, AND THAT ALL OF THE

INFORMATION I HAVE PROVIDED ON THIS FORM IS TRUE AND CORRECT.

SIGNATURE OF PARENT/LEGAL GUARDIAN DATE

los angeles unified school district early childhood

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