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1 DR. JACQUELINE ELLIOT Co-Founder DR. REF RODRIGUEZ Co-Founder ED VANDENBERG Regional Director NIK ORLANDO Regional Director MALENA OTERO Regional Director Dear Parent or Guardian/Estimado Padre o Tutor, Welcome to Partnerships to Uplift Communities (PUC) Schools. We look forward to having your son/daughter at one of our school for the school year. For your convenience, below is a list of the enrollment documents that you must return to the school in order to enroll your son/daughter. Please note that their enrollment will not be complete until all forms are turned in. Please refer to your Letter of Acceptance for more details. Bienvenidos a Escuelas Partnerships to Uplift Communities (PUC). Esperamos tener a su hijo / hija en una de nuestra escuela para el año escolar Para su conveniencia, a continuación hay una lista de los documentos de inscripción que debe regresar a la escuela con el fin de inscribir a su hijo / a. Por favor, tenga en cuenta que su inscripción no será completa hasta que todas las formas estén entregadas a la escuela. Por favor consulte la Carta de Aceptación para obtener más detalles. Enrollment Packet Check List/ Lista de Referencia de documentos de Inscripción: New Student Registration Form/ Forma de Registro para Nuevo Estudiante Emergency Information Form/ Formulario de Tarjeta de Emergencia Registry of Student s Health/ Registro de Salud del Estudiante Administration of Medication During School Hours/ Administración de Medicamento Durante Horas de Escuela Medical Statement to Request Special Meals and/or Accommodations/ Declaración Medica, Comidas y/o Alojamientos Especiales Acceptable Computer Use Policy / Póliza aceptable del Uso de Computadoras Photo & Video Release and Consent Agreement / Permiso y Consentimiento para Tomar Fotografías y Grabar Videos Permission to Leave School Grounds/Permiso Para Salir de la Escuela Durante Horas de Instrucción Student Textbook Contract / Contrato de Estudiante para Libros de Texto Individualized Education Plan (IEP) (ONLY if your child is receiving Special Education Services) Programa de Educación Individualizado (IEP) (SOLAMENTE si su hijo/a recibe Servicios de Educación Especial) If your child had a Section 504 Plan at his/her previous school, please submit a copy of the plan to our school. Si su hijo/a tenía un Plan de Sección 504 en su escuela anterior, por favor entregué una copia del plan a nuestra escuela. Birth Certificate or Passport/Acta de Nacimiento o Pasaporte Immunization Record /Registro de Inmunización PAR Report/Reporte PAR Please contact your school s main office for due dates to return these forms. If we do not receive the enrollment forms by the due date, the office staff will contact you to determine if you would still like to enroll your son/daughter. If we have not heard back from you after several attempts, we will move on to the next person on the waiting list. Por favor, póngase en contacto con la oficina principal de su escuela para las fechas de entregar estos formularios. Si no recibimos los formularios de inscripción en la fecha que se deben de entregar, el personal de la oficina se comunicará con usted para determinar si usted todavía desea inscribir a su hijo/a. Si no recibimos respuesta de usted después de varios intentos, vamos a pasar a la siguiente persona en lista de espera.

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3 A. Student Information NEW STUDENT REGISTRATION FORM First Name: Middle Name: Last Name: Home Address: Apt#: City: State: Zip: Mailing Address (If different from home address): Apt # City: State: Zip: Phone: Date of Birth: / / In what language would you like to receive communication from PUC schools? English Spanish Student s Gender: Female Male City, State and Country of Birth: ETHNICITY: Mark the ethnicity with which the student most closely identifies: Please check one: (Used for state/federal reporting only) Please answer both questions Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race) Not Hispanic or Latino Decline to State WHAT IS YOUR CHILD S RACE (Please check up to five racial categories)? The above part of the question is about ethnicity, not race. No matter what you selected above, please continue to answer the following by marking one or more boxes to indicate what you consider your race to be. (Used for state/federal reporting only). American Indian or Alaskan Native (100) Korean (203) Hawaiian (301) African American or Black (600) (Person having origins in any of the Vietnamese (204) Guamanian (302) White (700) original people of North and South Asian Indian (205) Samoan (303) (Persons having origins in any America (including Central America) Laotian (206) Tahitian (304) of the original peoples of Europe, Cambodian (207) Other Pacific Islander (399) North Africa, or the Middle East) Chinese (201) Hmong (208) Filipino/Filipino American (400) Japanese (202) Other Asian (299) Decline to State Student is Applying for Grade: 6 th Grade 7 th Grade 8 th Grade Please mark how many times the student has ever entered this grade level: First Time Second Time Has your student ever been accepted or attended another PUC School? Yes No If Yes, list the name of the school: B. Home Language Survey *If Chinese, please specify dialect: What language did this student learn when he or she first began to talk? What language does this student most frequently use at home? What language do you use most frequently to speak to this student? Which language is most often used by the adults at home? Has this student received any formal English language instruction (listening, speaking, reading, or writing)? Yes No 1

4 FORMA DE REGISTRACIÓN DE NUEVO ESTUDIANTE A. Información del Estudiante Nombre: Segundo Nombre: Apellido: Domicilio del Hogar: Apt#: Cuidad: Estado: Código Postal: Domicilio Postal (Si difiere al de arriba): Apt#: Cuidad: Estado: Código Postal: Teléfono: Fecha de nacimiento: / / En qué idioma le gustaría recibir comunicación de las escuelas de PUC? Ingles Español Sexo del Estudiante Femenino Masculino Ciudad, Estado y País de Nacimiento: ETNIA: Cual es la etnicidad de su hijo/a?: Marque una: (Se utiliza para informes estatales / federales solamente) Favor de responder a las dos preguntas Hispano/Latino (Una persona cuya cultura u origen es de Cuban, México, Puerto Rico, Centro o Sudamérica, sin importar su raza) No Hispano o Latino Niego a declarar CUAL ES LA RAZA DE SU HIJO/A? (Por favor no marque más de cinco opciones) La parte de la pregunta que aparece arriba es sobre etnicidad, no sobre raza. Independientemente de la opción que elija, favor de continuar respondiendo lo que sigue, marcando uno o más de los cuadritos, para indicar la que considera que es su raza. (Se utiliza para informes estatales / federales solamente) Indígena Americano o nativo de Alaska (100) Corean (203) Hawaiano (301) Afroestadunidense o negro (600) (Personas cuyo origen es de los pueblos Vietnamita (204) Guames (302) Blanco (700) nativos de Norte, Centro o Sudamérica) Indio de Asia (205) Samoa (303) (Personas cuyo origen es de los Laos (206) Tahitiano (304) pueblos nativos de Europa, Norte Camboyano (207) Otro grupo de las de Africa o el Medio Oriente) Chino (201) Hmong (208) islas del Pacifico (399) Filipino/Filipino Americano (400) Japonés (202) Otro asiático (299) Niego a declarar Estudiante aplica para el grado: 9º Grado 10º Grado 11º Grado 12º Grado Cuantas veces el/la estudiante ha estado en este grado: Primera Vez Segunda Vez Alguna vez ha sido aceptado o ha asistido a otra escuela de PUC? Si No Si es Si, escriba el nombre de la escuela: B. Encuesta de Lenguaje en Casa *Si hablan Chino, que idioma: Qué idioma aprendió el estudiante cuando empezó a hablar? Qué idioma usa este estudiante más frecuente en casa? Qué idioma usa usted frecuente cuando habla con el estudiante? Qué idioma se usa más frecuente por los adultos en casa? Ha recibido el estudiante cualquier instrucción de Ingles formal (escuchar, hablar, leer, escribir)? Si No 2

5 C. Previous School Information (this information is used for making needed requests from prior schools) Before attending this charter school, the student attended: School City - State Dates Attended Grade Levels LAUSD School 1. Yes No 2. Yes No Date first enrolled in a U.S. School? / / Mo. / Day/ Year D. Does the student have any siblings? Name Age Current School E. Parent/Guardian/Family Information Mother: First Name: Last Name: Address: Apt#: City: State: Zip: Home Phone: Alternate Phone: Cell Phone: address: Father: First Name: Last Name: Address: Apt#: City: State: Zip: Home Phone: Alternate Phone: Cell Phone: address: Guardian: First Name: Last Name: Address: Apt#: City: State: Zip: Home Phone: Alternate Phone: Cell Phone: address: F. What is the highest level of education? (Used for state/federal reporting only) Mother: Not a High School Graduate High School Graduate Some College or Associate s Degree Graduate Degree or Higher College Graduate Decline to State Father: Not a High School Graduate High School Graduate Some College or Associate s Degree Graduate Degree or Higher College Graduate Decline to State Guardian: Not a High School Graduate High School Graduate Some College or Associate s Degree Graduate Degree or Higher College Graduate Decline to State 3

6 C. Información de la Escuela Anterior (esta información se utiliza para hacer solicitudes necesarias de las escuelas anteriores) Antes de asistir a esta escuela Chárter, el/la estudiante asistió: Escuela Cuidad Estado Fecha Nivel de grado Escuela de LAUSD 1. Si No 2. Si No Fecha en que asistió por vez primera a la escuela en EE.UU / / Mes / Día / Año D. Tiene el estudiante hermanos o hermanas? Nombre Edad Escuela que asiste E. Padre/Guardian/Información de la Familia Madre: Primer Nombre: Apellido: Domicilio: Apt#: Cuidad: Estado: Código Postal: Teléfono de Casa: Alternativa: Celular: Correo electrónico: Padre: Primer Nombre: Apellido: Domicilio: Apt#: Cuidad: Estado: Código Postal: Teléfono de Casa: Alternativa: Celular: Correo electrónico: Guardian: Primer Nombre: Apellido: Domicilio: Apt#: Cuidad: Estado: Código Postal: Teléfono de Casa: Alternativa: Celular: Correo electrónico: F. Cuál es el nivel educativo más alto? (Se utiliza para informes estatales / federales solamente) Madre: No Graduado de Escuela Preparatoria Diploma Preparatoria Niego a declarar Algo de educación de colegio o universidad sin titulo Graduado de Colegio Ingresado en la Universidad Graduado Escuela de Posgrado Padre: No Graduado de Escuela Preparatoria Diploma Preparatoria Niego a declarar Algo de educación de colegio o universidad sin titulo Graduado de Colegio Ingresado en la Universidad Graduado Escuela de Posgrado Guardián: No Graduado de Escuela Preparatoria Diploma Preparatoria Niego a declarar Algo de educación de colegio o universidad sin titulo Graduado de Colegio Ingresado en la Universidad Graduado Escuela de Posgrado 4

7 G. Residence Where is the student living? (Federally mandated by NCLB: Please check appropriate box) In a single family permanent residence (house, apartment, condo, mobile home) In a motel/hotel Doubled-up (sharing housing with other families/individuals due to economic hardship, loss, or other reasons) Unsheltered (car/campsite) In a sheltered or transitional housing program Other Student lives with (check all that apply): Both parents Mother Father Guardian Relative Both parents alternately: Mother-Stepparent Father-Stepparent Foster home Group home/adult Residential Facility Licensed Children's Institute Self as emancipated minor Other H. Court Orders Are there any court orders restricting the legal rights of either parent? Yes No If Yes please provide us a copy of the court order. I. Special Services A. Does this student have an Individualized Education Program (IEP) at his/her previous school? Yes No If yes, please submit a copy of the student s IEP to our school. B. Does this student receive special education services such as Speech, Occupational Therapy, Physical Therapy or Adaptive P.E. at his/her previous school? Yes No If yes, what services were they? C. If yes to A or B please complete a Consent to Release Confidential Student Information form available at the school s main office. D. Does this student have a Section 504 Plan at his/her previous school? Yes No If yes, please submit a copy of the students Section 504 Plan to our school. E. Does this student have difficulties that interfere with his/her ability to go to school? Yes No F. Does this student have difficulties that interfere with his/her ability to read and/or do math? Yes No G. Has this student been identified for gifted and talented educational services (Gate)? Yes No SIGNATURE OF PARENT/GUARDIAN I verify that this information is true and correct. X Print Name: Date Relation: 5

8 G. Residencia Dónde vive el estudiante? (Federalmente puesto bajo el mandato por NCLB: Por favor marque la casilla apropiada) En una residencia permanente con la familia (casa, apartamento, condominio, casa móvil) En un motel/hotel Con más de una familia en una casa o apartamento Sin residencia (carro o campamento) En un refugio o programa de vivienda en transición Otra Estudiante vive con (marque todos los que apliquen): Ambos padres Madre Padre Guardián Pariente Ambos padres alternamente Madrastra Padrastro Casa provisional Instalación residencial para adultos Instituto aprobado para niños Solo como menor de edad emancipado Otro: H. Ordenes de la Corte Hay alguna orden de un tribunal que restrinja los derechos de alguno de los padres? Si No Si usted contesto "Si" por favor proporcione una copia de la orden del tribunal. I. Servicios Especiales A. Tiene el estudiante un Programa de Educación Individualizado (IEP) en su escuela anterior? Si No Si es Si, entregué una copia del IEP del estudiante a la escuela. B. Recibe el estudiante servicios de educación especial, tales como de Habla, Terapia Ocupacional, Terapia Física o Adaptación de Educación Física en su escuela anterior? Si No Si recibe servicios, cuales servicios recibe? C. Si respondió Si a A o B, favor de llenar una forma de Consentimiento para Divulgar Información Confidencial del Estudiante que está disponible en la oficina principal de la escuela D. Tiene el estudiante un Plan de Sección 504 en su escuela? Si No Si es Si, entregué una copia del plan 504 del estudiante a la escuela. E. Tiene el estudiante dificultades que le impiden su habilidad de asistir a la escuela? Si No F. Tiene este estudiante dificultades que le impiden su habilidad de leer o hacer matemáticas? Si No G. El estudiante ha sido identificado como un estudiante súper dotado (GATES)? Si No FIRMA DE PADRE/GUARDIAN Yo aseguro que esta información es verdadera y correcta. X Nombre en imprenta: Fecha: Relación: 6

9 STUDENT EMERGENCY INFORMATION 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. Birth Date Male Female Grade Home Language Height Weight Hair Color Eye Color Blood Type 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 Home Work Cell 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 Home Work Cell In case of an emergency please call Home Work Cell In case of an emergency please call Home Work Cell Address Address 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 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 Grade Relationship to Student Last Name First Name Grade Relationship to Student Please list any allergies that your child has Allergy 1 Allergy 2 Allergy 3 My child does not have any allergies AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT The undersigned, as parent/legal guardian of, a minor, hereby authorizes the principal or designee, into whose care the student (Print name of the student here) 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 of any required diagnosis, treatment, or hospital care and provides authority and power to Partnership to Uplift Communities ( PUC) 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 of the California Education Code, and shall remain effective until revoked in writing and delivered to PUC. I understand that PUC, its officers and its employees assume no liability of any nature in relation to the transportation 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. Does the student have health insurance? (check one) Yes No If "Yes": Private Health Insurance Medi-Cal Healthy Families Name of Doctor/Medical Office Phone Number of Doctor/Medical Office Group No. Please list any medications that your child is taking Medication 1 Frequency Medication 2 Frequency Medication 3 Frequency I CERTIFY THAT I HAVE READ AND UNDERSTOOD THIS FORM AND DO HERBY GIVE MY AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT, AND THAT ALL OF THE INFORMATION I HAVE PROVIDED ON THIS FORM IS TRUE AND CORRECT. X Signature of Parent/Legal Guardian Date 7

10 Please attached a recent photo of your child Por favor, adjunta una foto reciente de su hijo/a FORMULARIO ESTUDIANTIL DE INFORMACIÓN PARA EMERGENCIAS Información para Padres: Favor de llenar este formulario por completo y firmar en la sección indicada. En caso de una emergencia grave las normas del distrito escolar requieren mantener a los alumnos en la escuela por su seguridad. El personal escolar usará este formulario cuando los alumnos sean permitidos volver a casa. Favor de llenar electrónicamente o con letra de molde clara y entregar el formulario completo en la escuela. Apellido Del Alumno Nombre Inicial Fecha De Nacimiento Masc. Femen. Grado Idioma que se habla en casa Estatura Peso Color de Cabello Color de Ojos Tipo de Sangre Domicilio del Alumno - Numero Calle APT # Ciudad Código Postal Domicilio Postal - Numero (Si difiere al de arriba) Calle APT # Ciudad Código Postal Apellido del Padre/Tutor Legal Nombre Parentesco al Alumno Vive con el Alumno Dirección del Trabajo Calle Ciudad Código Postal Números telefónicos de contacto Hogar Trabajo Celular Números telefónicos de contacto Hogar Trabajo Celular En caso de emergencia por favor llame a mi Hogar Trabajo Celular Apellido del padre/tutor legal Nombre Parentesco al Alumno Vive con el Alumno Dirección del Trabajo Calle Ciudad Código Postal En caso de emergencia por favor llame a mi Hogar Trabajo Celular Correo Electrónico Al director: En caso de que no me pueden localizar durante una emergencia, le autorizo a contactar y, de ser necesario, entregarle a mi niño a cualquiera de las siguientes personas: Nombre Parentesco Tel. del Hogar Tel. de Celular Tel. del Trabajo Si Correo Electrónico Si No No Nombre Parentesco Tel. del Hogar Tel. de Celular Tel. del Trabajo Nombre Parentesco Tel. del Hogar Tel. de Celular Tel. del Trabajo Incluir cualquier otro miembro de la familia que asista a esta escuela: Apellido Nombre Grado Parentesco al Alumno Apellido Nombre Grado Parentesco al Alumno Por favor indique cualquier alergia que tenga su hijo/a Alergia 1 Alergia 2 Alergia 3 Mi hijo/a no tiene alergias AUTORIZACIÓN PARA TRATAMIENTO MÉDICO DE EMERGENCIA El abajo firmante, como padre/tutor legal de, menor de edad, por medio del presente autoriza al director (Escribir el nombre del alumno con letra de molde) o persona designada habiéndosele encomendado el cuidado del alumno, a acceder a cualquier análisis con radiografía, anestesia, diagnóstico médico o quirúrgico, tratamiento y/o atención en hospital para el alumno, según lo especifique un médico acreditado y/o dentista. Estoy al tanto de que esta autorización se extiende antes de cualquier diagnóstico, tratamiento o atención en hospital necesaria y otorgo la autoridad y facultad a Partnership to Uplift Communities ( PUC ) de dar consentimiento a todo y cualquier diagnóstico, tratamiento, o atención en hospital con un médico acreditado o dentista conforme se determine necesario. Esta autorización se extiende de acuerdo con el Artículo del Código de Educación de California, y seguirá en vigencia hasta que se revoque por escrito y dicha revocación se entregue a PUC. Entiendo que PUC, sus funcionarios y empleados no asumen responsabilidad de cualquier índole en relación con el transporte del alumno. También estoy al tanto de que el costo de transporte de paramédicos, hospitalización, análisis, radiografías, o tratamiento que se proporcione en relación con esta autorización será responsabilidad exclusivamente mía, como padre/tutor del alumno. Indicar se el alumno tiene seguro medico? (marcar uno) Si No Si respondió "Si" indique: Seguro medico Particular Medi-Cal Healthy Families Nombre del doctor/clínica Numero Telefónico del Doctor/Clínica Grupo # Por favor indique los medicamentos que su hijo/a esta tomando Medicamento 1 Frecuencia Medicamento 2 Frecuencia Medicamento 3 Frecuencia HAGO CONSTAR QUE LEÍ Y ENTIENDO ESTE FORMULARIO Y OTORGO MI AUTORIZACIÓN PARA TRATAMIENTO MÉDICO DE EMERGENCIA, Y QUE TODA LA INFORMACIÓN QUE PROPORCIONÉ EN ESTE FORMULARIO ES VERÍDICA Y CORRECTA. X Firma del Padre/Tutor Legal Fecha 8

11 REGISTRY OF STUDENT S HEALTH Student s Name: Birth Date: LAST FIRST MIDDLE MM / DD / YY Sex: M F Current Grade: Mark any condition for which your child has received health care: Asthma or chronic lung condition Seizures Diabetes Heart Kidney Blood Diseases Other: List further information about any of the above conditions: Does your child have any allergies? Yes No Do they require the use of an EpiPen? Yes No If Yes, please list allergies: Health Care Provider and Physician: Past Medical History Problems at birth: Serious illness/injury, hospitalization, explain: Medical Condition Vision Problems: Yes No Wears Glasses/Contacts Yes No Hearing Loss Yes No Ear Aches/ Infections Yes No Speech Problems Yes No Does your student require any medication administered during school hours? Yes No If yes, please complete an ADMINISTRATION OF MEDICATION DURING SCHOOL HOURS RELEASE FORM Are physical activities limited? Yes No If yes, reason for limitation: If you have any questions/concern or additional information about your child s health, call your school nurse. Parent/Guardian Signature 9 / / Date

12 REGISTRO DE SALUD DEL ESTUDIANTE Nombre del Estudiante: Fecha de Nacimiento: APELLIDO NOMBRE SEGUNDO NOMBRE MM / DD / AA Sexo del Estudiante: M F Grado Actual: Marque cualquier condición por la que su niño(a) ha recibido atención médica: Asma Ataques Condición Acrónica de los Pulmones Diabetes Corazón Riñones Enfermedad de la Sangre Otro: Por favor anote más información sobre cualquier condición marcada: Tiene alergias su hijo/a? Si No Requieren el uso de un EpiPen? Si No Si respondió Si, favor de indicar las alergias: Plan de Salud y Proveedor Medico: Antecedentes médicos del Niño/a: Problemas de nacimiento: Enfermedades o heridas serias, hospitalización. Explique: Condición Médica Problemas Visuales: Si No Usa Anteojos/Lentes de Contacto Si No Dolores de Oídos/Infecciones Si No Pérdida de Peso Si No Problemas con el habla Si No Su estudiante requiere algún medicamento que se le tenga que administrar durante horas de escuela? Si No Contesto Si, por favor complete LA FORMA PARA ADMINISTRAR MEDICAMENTO DURANTE HORAS ESCOLARES. Hay algunas restricciones en las actividades físicas? Si No Si la respuesta es SI explique la razón: Si usted tiene alguna pregunta/preocupación o necesita mayor información sobre la salud de su niño (a) comuníquese con la escuela. Firma Padre/Guardian / / Fecha 10

13 ADMINISTRATION OF MEDICATION DURING SCHOOL HOURS Student Name: Birth date: Address: Home Phone: Grade: THIS SECTION TO BE COMPLETED BY HEALTH CARE PROVIDER TO THE HEALTH CARE PROVIDER: Please complete and sign the center section of this form when prescription or non-prescription medication must be given during school hours. This form is required by Section , California Education Code, to authorize school personnel to assist the students with the administration of medication. Date: Diagnosis or reason for medication: Medication prescribed, strength, dosage, time to be taken: Any special instruction, precautions, or possible side effects: How long will this medication be necessary? Signature of Health Care Provider: Phone: Printed Name of Health Care Provider: Address: THIS SECTION TO BE COMPLETED BY PARENT/GUARDIAN TO THE PARENT/GUARDIAN: The medication must be delivered to the school in the original pharmacy container. The parent/guardian must bring the medication to the office. PLEASE SIGN THE FOLLOWING STATEMENT: I request that the school assist my child in taking the medication as directed above, and in accordance with the school policy. Signature of parent/guardian: Date: 11

14 ADMINISTRACIÓN DE MEDICAMENTO DURANTE HORAS ESCOLARES Nombre del Estudiante: Fecha de Nacimiento: Domicilio: Número Telefónico: Grado: Maestro: ESTA SECCIÓN DEBE SER COMPLETADA POR EL PROVEEDOR MEDICO TO THE HEALTH CARE PROVIDER: Please complete and sign the center section of this form when prescription or non-prescription medication must be given during school hours. This form is required by Section , California Education Code, to authorize school personnel to assist the students with the administration of medication. Date: Diagnosis or reason for medication: Medication prescribed, strength, dosage, time to be taken: Any special instruction, precautions, or possible side effects: How long will this medication be necessary? Signature of Health Care Provider: Phone: Printed Name of Health Care Provider: Address: ESTA SECCIÓN DEBE SER COMPLETADA POR EL PADRE/GUARDIÁN PARA EL PADRE/GUARDIAN: El medicamento debe de ser entregado a la escuela en el empaque original de la farmacia. El Padre/Guardián deberá de entregar el medicamento a la oficina. FAVOR DE FIRMAR LA SIGUIENTE DECLARACION: Yo le pido a la escuela en asistir a mi hijo(a) en tomar sus medicamentos como han sido recetados, y de acuerdo con la póliza de la escuela. Firma del Padre/Guardián: Fecha: 12

15 CALIFORNIA DEPARTMENT OF EDUCATION CHILD NUTRITION PROGRAMS NUTRITION SERVICES DIVISION CNP-925 (REV. 04/07) MEDICAL STATEMENT TO REQUEST SPECIAL MEALS AND/OR ACCOMMODATIONS 1. SCHOOL/AGENCY 2. SITE 3. SITE TELEPHONE NUMBER 4. NAME OF PARTICIPANT 5. AGE OR DATE OF BIRTH 6. NAME OF PARENT OR GUARDIAN 7. TELEPHONE NUMBER 8. CHECK ONE: Participant has a disability or a medical condition and requires a special meal or accommodation. (Refer to definitions on reverse side of this form.) Schools and agencies participating in federal nutrition programs must comply with requests for special meals and any adaptive equipment. A licensed physician must sign this form. Participant does not have a disability, but is requesting a special meal or accommodation due to food intolerance(s) or other medical reasons. Food preferences are not an appropriate use of this form. Schools and agencies participating in federal nutrition programs are encouraged to accommodate reasonable requests. A licensed physician, physician s assistant, or registered nurse must sign this form. 9. DISABILITY OR MEDICAL CONDITION REQUIRING A SPECIAL MEAL OR ACCOMMODATION: 10. IF PARTICIPANT HAS A DISABILITY, PROVIDE A BRIEF DESCRIPTION OF PARTICIPANT S MAJOR LIFE ACTIVITY AFFECTED BY THE DISABILITY: 11. DIET PRESCRIPTION AND/OR ACCOMMODATION: (PLEASE DESCRIBE IN DETAIL TO ENSURE PROPER IMPLEMENTATION) 12. INDICATE TEXTURE: Regular Chopped Ground Pureed 13. FOODS TO BE OMITTED AND SUBSTITUTIONS: (PLEASE LIST SPECIFIC FOODS TO BE OMITTED AND SUGGESTED SUBSTITUTIONS. YOU MAY ATTACH A SHEET WITH ADDITIONAL INFORMATION) A. Foods To Be Omitted B. Suggested Substitutions 14. ADAPTIVE EQUIPMENT: 15. SIGNATURE OF PREPARER* 16. PRINTED NAME 17. TELEPHONE NUMBER 18. DATE 19. SIGNATURE OF MEDICAL AUTHORITY* 20. PRINTED NAME 21. TELEPHONE NUMBER 22. DATE * Physician s signature is required for participants with a disability. For participants without a disability, a licensed physician, physician s assistant, or registered nurse must sign the form. The information on this form should be updated to reflect the current medical and/or nutritional needs of the participant. In accordance with Federal law and U.S. Department of Agriculture policy, this agency is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, DC , or call (voice and TDD). USDA is an equal opportunity provider and employer. 13

16 CALIFORNIA DEPARTMENT OF EDUCATION CHILD NUTRITION PROGRAMS NUTRITION SERVICES DIVISION CNP-925 (REV. 04/07) MEDICAL STATEMENT TO REQUEST SPECIAL MEALS AND/OR ACCOMMODATIONS INSTRUCTIONS 1. School/Agency: Print the name of the school or agency that is providing the form to the parent. 2. Site: Print the name of the site where meals will be served (e.g., school site, child care center, community center, etc.) 3. Site Telephone Number: Print the telephone number of site where meal will be served. See #2. 4. Name of Participant: Print the name of the child or adult participant to whom the information pertains. 5. Age of Participant: Print the age of the participant. For infants, please use Date of Birth. 6. Name of Parent or Guardian: Print the name of the person requesting the participant s medical statement. 7. Telephone Number: Print the telephone number of parent or guardian. 8. Check One: Check () a box to indicate whether participant has a disability or does not have a disability. 9. Disability or Medical Condition Requiring a Special Meal or Accommodation: Describe the medical condition that requires a special meal or accommodation (e.g., juvenile diabetes, allergy to peanuts, etc.) 10. If Participant has a Disability, Provide a Brief Description of Participant s Major Life Activity Affected by the Disability: Describe how physical or medical condition affects disability. For example: Allergy to peanuts causes a life-threatening reaction. 11. Diet Prescription and/or Accommodation: Describe a specific diet or accommodation that has been prescribed by a physician, or describe diet modification requested for a non-disabling condition. For example: All foods must be either in liquid or pureed form. Participant cannot consume any solid foods. 12. Indicate Texture: Check () a box to indicate the type of texture of food that is required. If the participant does not need any modification, check Regular. 13. A. Foods to Be Omitted: List specific foods that must be omitted. For example, the exclude fluid milk. B. Suggested Substitutions: List specific foods to include in the diet. For example, calcium fortified juice. 14. Adaptive Equipment: Describe specific equipment required to assist the participant with dining. (Examples may include a sippy cup, a large handled spoon, wheel-chair accessible furniture, etc.) 15 Signature of Preparer: Signature of person completing form. 16. Printed Name: Print name of person completing form. 17. Telephone Number: Telephone number of person completing form. 18. Date: Date preparer signed form. 19. Signature of Medical Authority: Signature of medical authority requesting the special meal or accommodation. 20. Printed Name: Print name of medical authority. 21. Telephone Number: Telephone number of medical authority. 22. Date: Date medical authority signed form. DEFINITIONS*: A Person with a Disability is defined as any person who has a physical or mental impairment which substantially limits one or more major life activities, has a record of such impairment, or is regarded as having such an impairment. Physical or mental impairment means (a) any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the following body systems: neurological; musculoskeletal; special sense organs; respiratory, including speech organs; cardiovascular; reproductive, digestive, genito-urinary; hemic and lymphatic; skin; and endocrine; or (b) any mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities. Major life activities are functions such as caring for one s self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working. Has a record of such an impairment is defined as having a history of, or have been classified (or misclassified) as having a mental or physical impairment that substantially limits one or more major life activities. (*Citations from Section 504 of the Rehabilitation Act of 1973) 14

17 CALIFORNIA DEPARTMENT OF EDUCATION CHILD NUTRITION PROGRAMS NUTRITION SERVICES DIVISION CNP-925 (REV. 04/07) DECLARACION MÉDICA COMIDAS Y/O ALOJAMIENTOS ESPECIALES 1. ESCUELA /AGENCIA 2. SITIO 3.NUMERO DE TELÉFONO DE SITIO 4. NOMBRE DE PARTICIPANTE 5. EDAD O FECHA DE NACIMIENTO 6. NOMBRE DE PADRE O GUARDIAN 7. NUMERO TELEFÓNICO 8. VERIFIQUE UNO: El participante tiene una incapacidad o una condición médica y requiere una comida o alojamiento espéciale. (Refiérase a las definiciones atrás de este formulario.) Las escuelas y las agencias que toman parte en los programas federales de nutrición deben conformarse con peticiones para comidas especiales y equipo capaz de adaptación. Un médico licenciado debe firmar esta orden. El participante no tiene una incapacidad, pero solicita una comida o alojamiento espéciale debido a intolerancia(s) de alimento o otras razones médicas. Las preferencias del alimento no son un uso apropiado de esta forma. Las escuelas y las agencias que toman parte en los programas federales de nutrición son favorecidas a acomodar peticiones razonables. Un médico licenciado, el ayudante de médico, o la enfermera titulada deben firmar esta orden. 9. LA INCAPACIDAD O LA CONDICIÓN MEDICA QUE REQUIEREN UNA COMIDA O EL ALOJAMIENTO ESPECIAL: 10. SI EL/LA PARTICIPANTE TIENE UNA INCAPACIDAD, PROPORCIONE UNA DESCRIPCIÓN BREVE DE LA ACIVILAD QUE AFECTA LA INCAPACIDAD: 11. LA DIETA PRESCRIPCIÓN Y/O EL ALOJAMIENTO: (POR FAVOR DESCRIBE EN DETALLE PARA ASEGURAR IMPLEMENTACIÓN APROPIADA) 12. INDIQUE LA TEXTURA DE LA COMIDA: Regular Cortado Suelto Licuado 13. LOS ALIMENTOS PARA SER OMITIDOS Y LAS SUBSTITUCIONES: (POR FAVOR NOMBRE LOS ALIMENTOS ESPECIFICOS QUE DEBEN SER OMITIDOS Y LAS SUBSTITUCIONES SUGERIDAS. PUEDE ADJUNTAR UNA HOJA CON INFORMACIÓN ADCIONAL) A. Los alimentos para ser omitidos B. Substituciones sugeridas 14. EQUIPO CAPAZ DE ADAPTACION: 15. FIRMA DEL PREPARADOR* 16. NOMBRE EN LETRA MOLDE 17. NUMERO DE TELEFONO 18. FECHA 19. FIRMA DE LA AUTORIDAD MEDICA 20. NOMBRE EN LETRA MOLDE 21. NUMERO DE TELEFONO 22. FECHA *La firma del médico es requerida para participantes con una incapacidad. Para participantes sin una incapacidad, un médico licenciado, el ayudante de médico, o la enfermera titulada deben firmar la forma. La información en este formulario debe ser actualizado para reflejar las necesidades médicas y/o nutricionales actuales del participante. De acuerdo a lo establecido por las leyes Federales y el departamento de Agricultura de los EE.UU. (USDA, siglas en inglés prohíben a este organización la discriminación por raza, color, origen nacional, sexo, edad, o impedimentos de las personas. (No todas las bases de prohibición se aplican a todos los programas.) Para presentar una queja sobre discriminación, escriba a USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, D. C , o llame al (202) (voz y TDD). USDA es un proveedor y empleador que ofrece oportunidad igual a todos. 15

18 CALIFORNIA DEPARTMENT OF EDUCATION CHILD NUTRITION PROGRAMS NUTRITION SERVICES DIVISION CNP-925 (REV. 04/07) DECLARACION MÉDICA COMIDAS Y/O ALOJAMIENTOS ESPECIALES INSTRUCIONES 1. Escuela/Agencia: Imprima el nombre de la escuela o la agencia que proporciona el formulario al padre. 2. Sitio: Imprima el nombre del sitio donde comidas serán servidas (por ejemplo, el sitio de la escuela, el centro de la guardería, el centro social, etc.) 3. Número de teléfono de sitio: Imprima el número de teléfono del sitio donde comida será servida. Vea #2. 4. Nombre de participante: Imprima el nombre del niño o participante adulto a quien la información pertenece. 5. Edad de participante: Imprima la edad del participante. Para niños, utiliza por favor la Fecha del Nacimiento. 6. Nombre de padre o guardián: Imprima el nombre de la persona que solicita la declaración médica de participante. 7. Número de teléfono: Imprima el número de teléfono de padre o guardián. 8. Verifique uno: Verifique () Una caja para indicar si participante tiene una incapacidad o no tiene una incapacidad. 9. La incapacidad o la condición médica que requieren una comida o el alojamiento especial: Describa la condición médica que requiere una comida o el alojamiento especial (por ejemplo, la diabetes juvenil, alergia a manís, etc.) 10. Si participante tiene una incapacidad, proporciona una descripción breve de la actividad de vida de mayor de participante afectada por la incapacidad: Describa la condición cuán física o médica afecta la incapacidad. Por ejemplo:" Alergia a manís causa una reacción de vida-amenazando". 11. La dieta prescripción y/o el alojamiento: : Describa una dieta o el alojamiento específico que ha sido prescrito por un médico, o describe la dieta la modificación solicitada para una condición que no-incapacita. Por ejemplo:" Todos alimentos deben ser o en forma de líquido o puré. El participante no puede consumir alimentos sólidos". 12. Indique la textura: Verifique () una caja para indicar el tipo de la textura de alimento que es requerido. Si el participante no necesita ninguna modificación, marque "Regular". 13. A. Los alimentos para ser omitidos: Anote alimentos específicos que deben ser omitidos. Por ejemplo, el "excluye leche líquida". B. Sustituciones sugeridas: Anote alimentos específicos para incluir en la dieta. Por ejemplo, "calcio fortificó jugo". 14. Equipo capaz de adopción: Describa equipo específico requerido a ayudar el participante con cenar. (Ejemplos pueden incluir una taza de sippy, una cuchara manejada grande, el sillón de ruedas muebles accesibles, etc.) 15 Firma del preparador: La firma de persona que completa formulario. 16. Nombre impreso: Imprima el nombre de persona que completa formulario. 17. Número de teléfono: El número de teléfono de persona que completa formulario. 18. Fecha: La fecha que se completo el formulario. 19. La firma de la Autoridad Médica: La firma de la autoridad médica que solicita la comida o el alojamiento espéciale. 20. Nombre impreso: Imprima el nombre de la autoridad médica. 21. Número de teléfono: El número de teléfono de la autoridad médica. 22. Fecha: La fecha en la cual la autoridad médica firma el formulario. DEFINICIONES*: Una Persona con una Incapacidad" es definido como cualquier persona que tiene un deterioro físico o mental que limita substancialmente uno o más actividades mayores de la vida, tiene un registro de tal deterioro, o es considerado teniendo como tal deterioro. "Deterioro físico o mental" significa (un) algún desorden o la condición fisiológicos, desfiguración cosmética, o afectar anatómico de pérdida uno o más de los siguientes sistemas del cuerpo: neurológico; musculo es quilatico; órganos sensoriales especiales; respiratorio, inclusive órganos de discurso; cardiovascular; reproductor, digestivo, genito urinario; hemic y linfático; piel; y el endocrino; o (B) algún desorden mental o psicológico, como el atraso mental, síndrome orgánico de cerebro, la enfermedad emocional o mental, y aprender específico las incapacidades. "Las actividades mayores de la vida" son las funciones como cuidar de un ser, realizando las tareas manuales, andar, ver, oído, hablar, respirar, aprender, y trabajar. "Tiene un registro de tal deterioro" es definido teniendo como una historia de, o ha sido clasificado (o misclassified) teniendo como un deterioro mental o físico que limita substancialmente uno o más actividades mayores de la vida. (*Citations from Section 504 of the Rehabilitation Act of 1973) 16

19 ACCEPTABLE USE POLICY Partnership to Uplift Communities Acceptable Use Policy ( AUP ) is to prevent unauthorized access and other unlawful activities by users online, prevent unauthorized disclosure of or access to sensitive information, and to comply with the Children s Internet Protection Act ( CIPA ). As used in this policy, user includes anyone using the computers, Internet, , chat rooms and other forms of direct electronic communications or equipment provided by PUC (the network. ). Only current students or employees are authorized to use the network. PUC will use technology protection measures to block or filter, to the extent practicable, access of visual depictions that are obscene, pornographic, and harmful to minors over the network. PUC reserves the right to monitor users' online activities and to access, review, copy, and store or delete any electronic communication or files and disclose them to others as it deems necessary. Users should have no expectation of privacy regarding their use of PUC property, network and/or Internet access or files, including . Acceptable Uses of the Partnership to Uplift Communities Computer Network or the Internet Schools must verify each year students using the computer network and Internet access for that school year have a signed page acknowledging this policy. Students who are under 18 must have their parents or guardians sign this page and schools must keep it on file. Once signed that permission/acknowledgement page remains in effect until revoked by the parent, or the student loses the privilege of using PUC s network due to violation of this policy or is no longer an PUC student. Employees and other users are required to follow this policy. Even without signature, all users must follow this policy and report any misuse of the network or Internet to a teacher, supervisor or other appropriate PUC personnel. Access is provided primarily for education and PUC business. Staff may use the Internet, for incidental personal use during duty-free time. By using the network, users have agreed to this policy. If a user is uncertain about whether a particular use is acceptable or appropriate, he or she should consult a teacher, supervisor or other appropriate PUC personnel. Unacceptable Uses of the Computer Network or Internet These are examples of inappropriate activity on the PUC web site, but PUC reserves the right to take immediate action regarding activities (1) that create security and/or safety issues for PUC, students, employees, schools, network or computer resources, or (2) that expend PUC resources on content PUC in its sole discretion determines lacks legitimate educational content/purpose, or (3) other activities as determined by PUC as inappropriate. Violating any state or federal law or municipal ordinance, such as: Accessing or transmitting pornography of any kind, obscene depictions, harmful materials, materials that encourage others to violate the law, confidential information or copyrighted materials; Criminal activities that can be punished under law; Selling or purchasing illegal items or substances; Obtaining and/or using anonymous sites; spamming; spreading viruses; Causing harm to others or damage to their property, such as: 1. Using profane, abusive, or impolite language; threatening, harassing, or making damaging or false statements about others or accessing, transmitting, or downloading offensive, harassing, or disparaging materials; 2. Deleting, copying, modifying, or forging other users' names, s, files, or data; disguising one's identity, impersonating other users, or sending anonymous ; 3. Damaging computer equipment, files, data or the network in any way, including intentionally accessing, transmitting or downloading computer viruses or other harmful files or programs, or disrupting any computer system performance; 4. Using any PUC computer to pursue hacking, internal or external to PUC, or attempting to access information protected by privacy laws; or 5. Accessing, transmitting or downloading large files, including "chain letters" or any type of "pyramid schemes". 17

20 Engaging in uses that jeopardize access or lead to unauthorized access into others accounts or other computer networks, such as: 1. Using another s account password(s) or identifier(s); 2. Interfering with other users' ability to access their account(s); or 3. Disclosing anyone s password to others or allowing them to use another s account(s). Using the network or Internet for Commercial purposes: 1. Using the Internet for personal financial gain; 2. Using the Internet for personal advertising, promotion, or financial gain; or 3. Conducting for-profit business activities and/or engaging in non-government related fundraising or public relations activities such as solicitation for religious purposes, lobbying for personal political purposes. Student Internet Safety 1. Students under the age of eighteen should only access PUC Schools network accounts outside of school if a parent or legal guardian supervises their usage at all times. The student s parent or guardian is responsible for monitoring the minor s use; 2. Students shall not reveal on the Internet personal information about themselves or other persons. For example, students should not reveal their name, home address, telephone number, or display photographs of themselves or others; 3. Students shall not meet in person anyone they have met only on the Internet; and 4. Students must abide by all laws, this Acceptable Use Policy and all PUC security policies. 5. Students must abide by the Social networking safety policy in attachment B. 6. Students must abide by the Cyber bullying safety policy in attachment C. Penalties for Improper Use The use of a PUC account is a privilege, not a right, and misuse will result in the restriction or cancellation of the account. Misuse may also lead to disciplinary and/or legal action for both students and employees, including suspension, expulsion, dismissal from PUC employment, or criminal prosecution by government authorities. PUC will attempt to tailor any disciplinary action to the specific issues related to each violation. Disclaimer PUC makes no guarantees about the quality of the services provided and is not responsible for any claims, losses, damages, costs, or other obligations arising from use of the network or accounts. Any additional charges a user accrues due to the use of PUC s network are to be borne by the user. PUC also denies any responsibility for the accuracy or quality of the information obtained through user access. Any statement, accessible on the computer network or the Internet, is understood to be the author's individual point of view and not that of PUC, its affiliates, or employees. I have read, understand, and agree to abide by the provisions of the Acceptable Use Policy of Partnership to Uplift Communities Student Name: Parent/Legal Guardian Name: Student Signature: Parent/Legal Guardian Signature Please return this form to the school where it will be kept on file. It is required for all students that will be using a computer network and/or Internet access. 18

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