MILLBRAE SCHOOL DISTRICT

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1 MILLBRAE SCHOOL DISTRICT STUDENT REGISTRATION Registration Period: January 15, 2015 February 20, 2015 All forms must be complete. All forms must be signed and initialed. All completed forms must be returned to the school office of your resident school, by appointment. The following must be submitted to the school office in order for your student to be completely registered for school: Registration Packet - COMPLETED Birth Certificate Residency Verification Up-to-date Immunization Records Current TB Test Results (within the last 12 months) if registering for the first time in a California Public School (Example: Students from out of state or country, or first time registering for Transitional Kindergarten or Kindergarten) Kindergarten and Transitional Kindergarten: Physical Exam AFTER March 1, 2015 All 7th and 8th Grade students must have and provide proof of the whooping cough booster immunization, also called T-dap. TRANSITIONAL KINDERGARTEN All students who turn five (5) years old between September 2 December 2, 2015 (inclusive) may enroll in Transitional Kindergarten for the upcoming school year. Please contact your home school to schedule registration appointments. Green Hills School 401 Ludeman Lane Millbrae, CA Lomita Park School 200 Santa Helena Ave San Bruno, CA Meadows School 1101 Helen Drive Millbrae, CA Spring Valley School 817 Murchison Drive Millbrae, CA Taylor Middle School 850 Taylor Blvd. Millbrae, CA

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3 STUDENT NAME: SCHOOL: GRADE IN ADDRESS: PHONE NUMBER: TRANSITIONAL KINDERGARTEN Registration Document Check-Off List Place a check mark next to the completed/attached items. All forms must be complete, signed and/or initialed and must be returned to the school office of your resident school. PROOF OF RESIDENCY (REQUIRES TWO DOCUMENTS WITH PARENT/GUARDIAN NAME AND ADDRESS LISTED) Homeowner or Renter/Lessee: Grant Deed or Property Tax Bill or Original rental or lease agreement AND PG&E Bill or PG&E Confirmation of Service or Water Dept. bill Sub-Lease: A letter from the manager confirming sub-lease agreement and confirmation of residency at that address for registering family. NEW STUDENT REGISTRATION FORM PRIMARY LANGUAGE SURVEY RESIDENCY VERIFICATION AFFIDAVIT STUDENT RESIDENCY QUESTIONNAIRE **IF SHARED RESIDENCY: District s Verification of Shared Residency Form (please request form from school office if applicable) Proof of Residency documents as required above STUDENT ORIGINAL BIRTH CERTIFICATE (a copy will be made and original returned to you.) STUDENT HEALTH INVENTORY (completed by parent/guardian) REPORT OF HEALTH EXAMINATION FOR SCHOOL ENTRY/ CURRENT IMMUNIZATION RECORDS & DATES (completed by physician) Current TB Test Results (within the last 12 months) if registering for the first time in a California Public School (i.e. Students from out of the state or country, or first time registering in Transitional Kindergarten or Kindergarten) Transitional Kindergarten and Kindergarten: Physical Exam AFTER March 1, STUDENT Tdap BOOSTER & DATE (7 TH & 8 TH Grade Students only) PARENT/GUARDIAN IDENTIFICATION **IF APPLICABLE Copy of any supplemental services documents Current 504 Plan Current Individualized Education Program (IEP) **IF your student is currently being assessed, please attach any related documents (i.e. Assessment Plan)

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5 For Office Use Only: Id# School Grade _ Teacher Room Date _Year _ Millbrae School District New Student Registration Form Student Last Name (Apellido del Estudiante) Student First Name (Primer nombre del estudiante) MI Nickname (Apodo) Address (Domicilio), City (Ciudad), State (Estado), Zip Code (Codigo postal) Home Phone (Telefono de casa) Cell Phone (Telefono de cellular) Birthdate (Fecha de nacimiento) Gender (Sexo) Enrolled (Matriculados): Resident School (Escuela de residencia) Presently registered at another school? No (NO) Yes (SI) (Actualmente inscrito en otra escuela?) Shared Residency (Residencia compartida) If yes, which one? (En caso afirmativo, cual?) Intradistrict Agreement (Acuerdo dentro del disrito) Interdistrict Agreement (Acuerdo entre distrito) Name (Nombre) Address (Domicilio City, State, Zip (Domicilio, Estado, Codigo postal) Does your child have an active IEP (Individual Education Plan) (Tiene el estudiante un plan active de educacion Individual? No Yes Speech/Language (espicho/lenguaje) Special Day Class (Clase especial de dia) Resource (recurso) Is your child currently receiving any of the following services? (Please check all that apply) (El estudiante esta rcibiendo cual quiera de los siguientes servicios? (Por favor marque todos los que apliquen) GATE (Educaion para Dotados y Talentosos)** 504 Plan** ELL (aprendices del idioma ingles) Expulsion (expulsion)** ** If you have checked any of these programs, please attach the current 504 Plan or IEP. (Si la respuesta es si por favor adjuntar una copia dela documentacion) 1. Is student an Immigrant? (Inmigrante?) 2. If Immigrant, Which Country? (Si inmigrante, que pais?) 3. US Entry Date (Date of Immigration) (Entrado de fecha a los Estados Unidos No Yes 4. Date of Entry into CA Public Schools (Fecha de ingreso en las escuelas publicas de California? 5. Date of Entry into US Schools (Fecha de ingreso en las escuelas de Estados Unidos 6. Place of Birth? (Lugar de nacimiento? Month/Year (Mes/Ano) Month/Year (Mes/Ano) Country (Pais) City (Ciudad) State (Estado) 7. What is your student s ethnicity? (Please check only one.) (Etnicidad del estudiante? 8. What is your student s race? (Choose one or more.) Cual es la raza del estudiante?) Hispanic or Latino (500) Not Hispanic or Latino (Hispano o Latino) (No Hispano o Latino) American Indian/Alaska Native Black or African American White ASIAN Asian Indian Cambodian Chinese Filipino Hmong Laotian Other Asian Vietnamese NATIVE HAWAIIAN OR PACIFIC ISLANDER Guamanian Hawaiian Samoan Tahitian Other Pacific Islander

6 PARENT INFORMATION: (INFORMACION PARA LOS PADRES) With whom does the student live? (Please check all that apply) (Conquien vive el estudiante?) (Por favor marque todos los que apliquen) Mother (Madre) Father (Padre) Stepmother (Madrasta) Stepfather (Padrasto) Foster Parent(s) (Padres de crianza) Grandparent(s) (Abuelos) Aunt/Uncle (Tia/Tio) Shared Custody (Custodia compartida) Other (Otro) By providing your address, you are giving permission to receive school and classroom news and information by . (Proporcianando su direccion de correo electronico, usted esta dando permiso para recibir noticias de la escuela y salon de clases e informacion por correo electronico.) FATHER (PADRE) MOTHER (MADRE) Natural Stepfather (Padrasto) Other (Otro) Natural Stepmother (Madrasta) Other(Otro) Name (Nombre) Home Address (Domicilio de casa) City, State, Zip Code (Ciudad, Estado, Codigo postal) Home Phone (Telefone de casa) Cell Phone (Telefono cellular) Work Phone (Telefono de trabajo) (Direccion de correo electronico) Employer (Empleador) Occupation (Ocupacion) Education Level (Nivel de educacion) High School Graduate (Graduado de la escuela Secundaria) Not a High School Graduate (No me gradue de la secundaria) College Graduate (Graduado de la Universidad) Some College or Associate s Degree (Un poco de Universidad o titulo asociado) Graduate Degree or Higher (Titulo de grado o superior) Declined to State or Unknown (Declinar my respuesta) Name (Nombre) Home Address (Domicilio de casa) City, State, Zip Code (Ciudad, Estado, Codigo postal) Home Phone (Telefone de casa) Cell Phone (Telefono cellular) Work Phone (Telefono de trabajo) (Direccion de correo electronico) Employer (Empleador) Occupation (Ocupacion) Education Level (Nivel de educacion) High School Graduate (Graduado de la escuela Secundaria) Not a High School Graduate (No me gradue de la secundaria) College Graduate (Graduado de la Universidad) Some College or Associate s Degree (Un poco de Universidad o titulo asociado) Graduate Degree or Higher (Titulo de grado o superior) Declined to State or Unknown (Declinar my respuesta) OTHER CHILDREN IN HOUSEHOLD (Ostros Ninos en la familia) Last Name (Apellido) First Name (Primer Nombre) Birthdate (fecha de nacimiento) Gender (Sexo) School (Escuela)

7 EMERGENCY/HEALTH INFORMATION: (IMFORMACION DE EMERGENCIA Y SALUD) Doctor s Name Telephone (Nombre del doctor) (Telefono) Hospital Telephone (Hospital) (Telefono) Insurance Company Insurance ID # Plan/Policy # (Compania aseguradora) (Identificacion del seguro) (Plan/# de poliza) STUDENT MEDICAL CONDITIONS (Check all that apply) (CONDICIONES MEDICAS) (Todas las que apliquen) On Medication Yes No If yes, name of medication (Medicacion) (Si) (No) (Nombre de medicina) Allergies Yes No If yes, name allergies (Allergias) (Si) (No) (Nombre de allergias) PE Limitations Yes No If yes, name limitation(s) (Limitaciones de educacion fisica) (Si) (No) (Nombre de limitaciones) Please check if the student has any of the following: (Porfavor compruebe si el estudiante tiene cualquiera de los siguientes:) Heart Problems (Limitaciones de Corazon) Seizure Disorders (Ataques) Asthma (Asma) Diabetes (Diabetes) Glasses/Contacts (Lentes/contactos) Hearing Problems (Problemas de audicion) Explanations or comments about medical conditions that the school should be aware of: (Explicaciones o comentarios sobre condiciones medicas que la escuela necesite ser conscientes:) NOTE: If it is necessary for your child to take medication at school, you must provide the school with the physician s written instruction and your written permission. Medication at school must be kept in the original pharmacy container. No medicine of any kind (prescriptions or non-prescriptions drugs including aspirin or aspirin substitutes) will be given at school unless the above conditions are met. (NOTA: Si es necesario para que su hijo(a) tome medicina en la escuela, debe proveer a la escuela las instrucciones del medico por escrito y su autorizacion. Medicamentos en la escuela se debe mantener en el envase original de la farmacia. Ningun medicamiento de cualquier (prescripcion o medicamientos de tipo sin receta incluyendo, aspirina o sustituto de la aspirina) se dara en la escuela a menos que las condiciones anteriores se cumplen. ) If parents cannot be reached in an emergency, please contact: (Si los padres no puede ser contactados en caso de emergencia contacten a:) Name Day Time Phone Relationship (Nombre) (Numero de telefono durante el dia) (Relacion) Name Day Time Phone Relationship Name Day Time Phone Relationship I CONSENT (Doy mi consentimiento) I DO NOT CONSENT (No doy consentimiento) For emergency treatment if it is deemed necessary by the school authorities and after all efforts to reach the parent or designated adult have failed. Your son/daughter will be taken by ambulance at parent s expense to the nearest emergency facility (Para tratamiento de emergencia si se considera por las autoridades de la escuela y despues de todos los esfuerzos para localizar a los padres o adulto designado a fracasado. Su hijo(a) sera llevado por ambulancia a expensas de los padres a las instalaciones de emergencia mas cercana. I WILL NOTIFY THE SCHOOL IF THERE IS A CHANGE IN ANY OF THE INFORMATION ON THIS FORM. (VOY A NOTIFICAR A LA ESCUELA SI HAY UN CAMBIO EN ALGUNO DE LOS DATOS EN ESTE FORMULANO.) Parent/Guardian Signature (firma del padre/madre guardian) Date (Dia)

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9 Primary Language Survey California Education Code ; California Code of Regulations 5CCR 4304 Student Name (please print) School Grade A Home Language Survey is required of each newly enrolling student in a California public or non-public school. Answers of languages other than English on questions 1, 2, or 3 will trigger a state test of English language development. The purpose is to know the languages and educational needs of students, so we can provide access to the educational program and rapid fluency in English. Parents, please answer the following questions: 1. Which language did your child learn when he/she first learned to talk? 2. Which language does your child use most frequently at home? 3. Which language do you use most frequently at home? 4. Which language is most often spoken by the adults in your home? Parent Signature Date Student Name (please print) School Grade Una encuesta de idioma que se requiere de cada estudiante inscrito recientemente en una escuela pública de California o no pública. Respuestas de otros idiomas aparte del Inglés en las preguntas 1, 2, o 3 dará lugar a un examen estatal de desarrollo del idioma Inglés. El propósito es conocer las lenguas y las necesidades educativas de los estudiantes, por lo que puede proporcionar el acceso a los programas educativos y rápida fluidez en Inglés. Instrucciones para padres y tutores: 1. Qué idioma aprendió su hijo cuando empezó a hablar? 2. Qué idioma habla su hijo en casa con más frecuencia? 3. Qué idioma utilizan ustedes (los padres o tutores) con más frecuencia? cuando hablan con su hijo? 4. Qué idioma se habla con más frecuencia entre los adultos en el hogar? (padres, tutores, abuelos o cualquier otro adulto)? Parent Signature Date

10 Primary Language Survey California Education Code ; California Code of Regulations 5CCR 4304 Student Name (please print) School Grade 全 栆 䥲 帆 j 䤓 㖖 䯉 C 䰞 Cねᇵ 㟨 十 㽤 ᇶ(Education Code) 㦘 㽤 尐 㻑 㪰 24 檗 䭉 㹞 䞮 䞷 䤓 檼 崭 岏 ᇭ 㦻 彖 岙 㡋 㪰 㙟 䤓 憣 䲚 㦜 崹 咂 桫 摜 尐 ᇭ 䍉 栆 㒥 䥲 帆 j ヘ ソ24 檗 俵 揜 ⅴ 檕 C 嫛 抨 檔 㽤 尐 㻑 ᇭ 嵚 䥰 厌 嵚 㹞 櫛 㓏 㙟 䤓 䴉 䤌 壤 䦇 㑘 崭 岏 䤓 䳀 ᇭ 嵚 按 䆞 櫛 ᇭ 䄥 䭉 承 櫛 ᇭ 1. ヘ ソ 䤓 栚 ⱚ 剡 崹 崀 㣑 䤓 㢾 ❹ 䲽 崭 岏 2. ヘ ソ 䤓 㦏 デ 嶪 䤓 㢾 ❹ 䲽 崭 岏 ヘ ソ ( 栆 㒥 䥲 帆 j) 咖 ヘ ソ 䤓 M 嵖 㦏 デ 䞷 ❹ 䲽 崭 岏 孰 䤓 㒟 j ( 栆 ᇬ 䥲 帆 jᇬ 䯥 䓅 㹜 㒥 Ⅵ 㒟 j) 㦏 デ 嶪 䤓 㢾 ❹ 䲽 崭 岏 嵚 ₚ 槱 䦇 㑘 䤓 䴉 䤌 壤 仌 峊 㢝 㡴 㦮 䏅 㦻 嫷 M 俵 ヘ ソ 䤓 劐 ズ ( 栆 㒥 䥲 帆 j 仌 ) ( 㡴 㦮 )

11 MILLBRAE SCHOOL DISTRICT Millbrae, CA New Students Residency Verification Affidavit School Child s Name Current grade Birthdate Child lives with Mother Father Guardian Caregiver Adult s name Address** City Home Phone Work Phone **If you are not a resident of Millbrae School District, please inquire in the school office regarding interdistrict transfer requests. Please read and initial each of the following statements: The Millbrae School District will actively investigate all cases where it has reason to believe false information has been provided on District forms and may verify with home visits. (initial) The District may refer cases in which false information has been intentionally provided to the San Mateo District Attorney for further action and/or file civil action to recover damages incurred as a result of providing false information. (initial) Persons who provide false information on a District form are subject to criminal prosecution for perjury which is punishable by a fine and/or a prison term of up to four years in State prison (Fam. Code 6552; Pen. Code 118 & 126) (initial) Persons providing false information on an affidavit also are civilly liable for fraud, negligent misrepresentation, and negligence. Parties found civilly liable may be required to pay all damages caused to the District as a result of providing false information, as well as punitive damages. (Civ. Code 1709) (initial) Persons who induce, obtain or otherwise solicit another person to provide false information on an affidavit are subject to the same criminal prosecution, fines, and imprisonment as the person directly committing perjury. (Pen. Code 127) (initial) Investigations that reveal students were enrolled on the basis of providing false information will lead to immediate removal from the District. (initial)

12 Residency Verification Required Documentation showing address where living must be current and provided at time of registration before child enters school: Homeowners Rent or Lease One of the following: 1. current tax bill with name and address on it 2. current tax receipt with name and address on it 3. deed of trust with name and address on it AND One of the following: 1. current PG&E bill with name and address on it 2. current Water bill with name and address on it All of the following: 1. rental/lease agreement with residency s address, owner/manager s name and phone number for verification 2. current PG&E bill or Water bill with name and address on it unless utilities are included in the rental/lease agreement Signature of Parent/Guardian Date RESIDENCY VERIFICATION WHEN PARENTS LIVE IN MILLBRAE SCHOOL DISTRICT All new enrollees will be asked to provide proof of residency. Verification must be presented before the student will be admitted. Proof of residency may be required of enrolled students upon the request of District administration. 1. Home Ownership: Two of the following must be presented at the time of registration and must have the name/address of the parent/guardian on it: One of the following: a. Deed of Trust b. Assessor s bill c. Property Tax receipt AND One of the following: d. PG & E bill e. Water bill 2. Home Lease: The person who will be leasing will provide both a. The lease agreement AND b. PG&E bill with his/her name and address or if you haven t been billed yet, a receipt from PG & E showing transfer of PG&E services to new address or a water bill.

13 3. Apartment Rent or Lease: The person must provide all of the following: a. Manager s name and telephone number b. Rental/Lease agreement c. Current PG&E bill with his/her name and address or if not receiving a bill yet, a receipt from PG&E showing transfer of PG&E services to new address or water bill. d. If PG&E is included in rental payment, that should be stated in the Lease Agreement. 4. Sub-Lease: The person must provide all of the following: a. A letter from the manager stating that he/she is aware of the sub-lease agreement and that the registering family does live at that address under a sub-lease b. A copy of the sub-lease c. Manager s name and telephone number. 5. Sharing a Place of Residence: When parents and student are sharing a home or apartment with Millbrae School District residents, the following must be provided: a. A completed Verification of Shared Residence form signed by the parent/guardian and property owner/renter indicating that the registering family does live at that address. b. When students are enrolling under Sharing a Place of Residence, the registered resident must furnish proof of residence as indicated above.

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15 STUDENT RESIDENCY QUESTIONNAIRE This document is intended to address the McKinney-Vento Assistance Act Title X, Part C, of the No Child Left Behind Act. Your answers will help determine documents necessary to enroll your child quickly. Student: Birthdate: Grade: Male Female 1. Do you and your student live in a fixed, regular, adequate nighttime residence? Yes No If you marked Yes, stop here. Please skip to question#4. If you marked No, please continue with this form. 2. Where does the student stay at night? In a shelter In a motel/hotel In a car or RV At a campsite Transitional housing Temporarily with another family in a house, mobile home, or apartment (because the family does not have a place of its own) ** Please meet with the principal.** Other location 3. The student lives with: One parent Two parents A qualified relative Friend(s) An adult that is not the legal guardian Alone with no adult(s) 4. I am: The parent/legal guardian of the above-named student A qualified adult relative of the above-named student Relationship: I declare under penalty of perjury under the laws of this state that the information provided here is true and correct and of my own personal knowledge. Signature: Please Print Name: Residence (Street, City, Zip): Mailing Address (Street, City, Zip): Telephone: Cell Phone: Date:

16 CUESTIONARIO JURADA SOBRE LA RESIDENCIA DEL ESTUDIANTE La finalidad de este documento es en referencia a la Ley McKinney-Vento para Ayuda a las Personas sin Hogar (McKinney-Vento Assistance Act). Sus respuestas ayudarán a determinar qué documentos son necesarios para matricular a su hijo con rapidez. Estudiante: Fecha de nacimiento:: Grado: Hombre Mujer 1. Viven usted y su hijo(a) en una residencia regular y fija adecuada para pasar la noche? Si No Si respondió SI, deténgase aquí. Si respondió NO,continúe llenando el formulario. 2. Viven usted y su hijo(a) en: refugio en motel/hotel Automovil o vehiculo recreativo (RV) campamento Vivienda de transicion Temporalmente con otra familia en una casa, casa movil o apartamento (porque la familia no tiene su proprio lugar) **Favor de reunirse con el director.** Otro lugar 3. El estudiante vive con: Uno de los padres Los dos padres Un familiar calificado Amigo(s) Un adulto que no es su tutor legal Solo, sin ningun adulto 4. Yo: Soy el padre/madre o tutor legal del estudiante nombrando anteriormente Soy un adulto calificado, familiar del estudiante nombrando anteriormente Parentesco: Declaro, bajo pena de perjurio, de conformidad con las leyes del Estado de California, que la información anterior es verdadera y correcta y tengo de la misma un conocimiento personal. Firma: Escriba su nombre en letra de impreta: Residencia (Street, City, Zip) Direccion (Calle, ciudad, codigo postal): Telefono de casa: Telefono de cellular

17 MILLBRAE SCHOOL DISTRICT STUDENT REGISTRATION FOR SCHOOL YEAR Registration Period: January 15, 2015 February 20, 2015 Health Exams and Immunizations Required for Student Enrollment The following immunizations are now required for Kindergarten and New Students: 4 Polio (3 doses meet requirement if at least one was given on or after 4 th birthday) 5 DPT (4 doses meet requirement if at least one was given on or after the 4 th birthday) 2 nd MMR (one dose must be on or after 1 st birthday) Hepatitis B series (3 shots) Varicella (chickenpox) Vaccine or proof of the disease TB Test and Results (within the last 12 months) All students entering 7 th and 8th Grades must have and provide proof of the whooping cough booster immunization, also called T-dap. (Please see the following page, Guide To Immunizations Required for School Entry for additional information.) KINDERGARTEN and TRANSITIONAL KINDERGARTEN: Please have your physician perform a complete health examination on your child after March 1, 2015 and return the attached health examination form to the school office.

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19 IMPORTANT MESSAGE FOR PARENTS HEALTH EXAM AND IMMUNIZATIONS ARE REQUIRED FOR SCHOOL Success in school starts with a healthy child. Your child is required by California State Law to have a health check-up and immunizations (shots) before starting Kindergarten or First Grade. The health checkup may be done as early as (6) six months before your child starts Kindergarten and up to (3) three months after he/she starts First Grade. Immunizations, however, must be up-to-date before your child is admitted to school. The health exam should include: A complete health history A head-to-toe physical exam Vision and hearing tests Urine and blood tests Immunizations See your child s doctor for the health exam. If you do not have a doctor, call the Child Health and Disability Prevention Program (CHDP) at (650) for help in finding one. Children who have Medi-Cal can receive the exam free of charge. Children from low income families may also be eligible for these free exams through CHDP. When you take your child for the health exam be sure to take your child s Immunization Record (yellow card) and Report of Health Examination for School Entry form. (included in this packet) Return the completed health form and updated immunization record to your child s school as soon as your child has been seen by the doctor. If you do not want your child to get a health exam or immunizations, you will need to sign a waiver form at your child s school. If you have any questions, please call your child s school or CHDP at (650) August 2011 County of San Mateo IMPF

20 MENSAJE IMPORTANTE PARA PADRES DE FAMILIA PARA ENTRAR EN LA ESCUELA SU NIÑO/A NECESITA UN EXAMEN MEDICO Y VACUNAS El éxito en la escuela comienza con buena salud, por lo tanto, su niño/a necesita un examen médico y vacunas antes de empezar el kinder/primer año escolar, requerido por la ley estatal de California. El examen médico puede hacerse seis meses antes de empezar el kinder o hasta tres meses después de iniciar su primer grado. Recuerde que su niño/a debe estar al día con las vacunas antes de ser admitido en la escuela. El Examen Médico debe incluir: Una historia completa de salud Un examen físico de pies a cabeza Un examen de la vista y de los oídos Análisis de la sangre y de la orina Las vacunas que le hagan falta Visite al doctor de su niño(a) para un examen médico. Si no tiene undoctor, llame al Programa de Salud para La Prevención de Incapacidades en Niños y Jóvenes (CHDP) teléfono (650) para ayudarle a encontrar un medico Niños y jóvenes que tienen Medi-Cal pueden recibir exámenes de salud gratis. Niños y jóvenes en familias de bajos ingresos también pueden ser elegibles para exámenes médicos gratis a través del programa CHDP. Cuando vaya al Examen Médico asegúrese de llevar: Registro de vacunación (la tarjeta de vacunas amarilla) La forma Reporte del Examen de Salud para el Ingreso a la Escuela ("Report of Health Examination for School Entry") Lleve a la escuela el reporte de su niño(a) tan pronto el doctor se lo entregue. Si no desea que a su niño(a) se le examine o vacune, Ud.tiene que firmar una forma, "Renuncia Voluntaria para Recibir un Examen de Salud para Ingresar a La Escuela". Si tiene preguntas, por favor llame a la escuela o al programa CHDP, teléfono (650) August 2011 County of San Mateo IMPF

21 Student s Name: Address: Millbrae School District Student Health Inventory School: Date of Birth: Telephone #: Family Physician and #: Teacher: Family Dentist and #: Grade: Room #: Please check which of the following conditions your child has had and give his/her age at the time of the illness and whether he or she is still under care of a physician for this condition. 1. Allergies a. Bee stings b. Foods - specify : c. other: 2. Asthma 3. Diabetes 4. Heart Condition 5. Rheumatic fever 6. Kidney disease 7. Epilepsy 8. Convulsions 9. Polio 10. Serious accidents or injuries 11. Tuberculosis, or tuberculosis contact 12. Frequent or severe headaches 13. Frequent or severe dizziness 14. Fainting 15. Any problem with speech? 16. Any problem with hearing? 17. Any problem with vision? 18. Any problem with teeth? 19. Emotional problem Approximate Age Under Care of Physician 20. Is there any other physical condition that the school should be made aware of? 21. Is physical activity limited? Yes No 22. If yes, is there a physician s statement on file with the school? According to the school code, there must be a physician s written statement. glasses contact lenses hearing aid dental braces leg braces crutches corrective shoes other 23. Does your child have any condition which could be a school emergency? 24. Is your child presently taking any medicine prescribed by a physician? (Explain) Parent/Guardian Signature Date E10 registrationinfo

22 Distrito Escolar de Millbrae Informacion Sobre la Salud del Estudiante Nombre del alumno(a): Direccion: Telefono: Maestro de Clase: Grado: Aula No: Escuela: Feche de Nacimiento: Nombre del Medico: Nombre del Dentista: Por favor indicar cuales de las siguientes afecciones ha padecido o padece su hijo(a) y tambien indicar si se encuentra actualmente bajo tratamiento medico por ese padecimiento. Edad que comenzó Bajo cuidado médico 1. Alergias a. picada de abeja b. comidas (especifica) : c. otra: 2. Asma 3. Diabetes 4. Afecciones cardiacas 5. Fiebre reumatica 6. Enfermedades de los rinones 7. Epilepsia 8. Convulsiones 9. Poliomelitis 10. Accidentes graves o heridas graves 11. Tuberculosis o contactos con TB 12. Dolores de cabezas fuertes y frecuentes 13. Mareos fuertes y frecuentes 14. Desmayos 15. Problemas con el hablar 16. Problemas con los oídos 17. Problemas de la vista 18. Problemas de los dientes 19. Problemas de caracter emocional 20. Hay algun padecimiento en la salud de su niño(a) que considera importante y de informar a la escuela fuera de esta lista? Por favor explique al dorso de la hoja. 21. Tiene su hijo(a) alguna dificultad en cuanto a alguna actividad física? SI NO 22. Si la respuesta es SI ya le informó sobre ésto a la escuela? Si existe alguna condición que cause que su hijo(a) tenga una actividad física limitada, la escuela necesita una certificación médica y la cual debe de actualizarse cada seis meses. Si su hijo(a) utiliza cualquier aparato o instrumentos de los cuales la escuela debe de estar enterada? De ser así por favor marque. anteojos zapatos correctivos aparatos en las piernas aparato para el oído frenos para los dientes lentes de contacto cualquier otro muletas 23. Tiene su hijo(a) algun padecimiento de salud que podría presentarse una emergencis en la escuela? 24. Si la requesta es SI por favor explicar al reverso de la hoja Está su hijo(a) tomando alguna medicina bajo receta médica? Si la respuesta es SI, por favor explique Firma de los padres/guardian Fecha E11 Registrationinfo

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27 Millbrae School District 555 Richmond Drive, Millbrae, CA (fax) Dear Parents and Guardians, Keep Millbrae Schools Great Support BOTH the MEF and your PTA! Welcome to the Millbrae School District! We are so happy to receive your new enrollment to our fine schools here in Millbrae and count it an honor to be a part of your student s education. Our schools are GREAT because of the wonderful community, parents and staff that make each of our schools unique through hard work and collaboration on behalf of children. All of us play an important role in making your student s years here in the Millbrae School District a positive, rigorous learning experience. In a time of slow fiscal recovery in our State and the continued lack of funding to Public Education, both the PTA and the MEF play critical roles at our schools. It is only through the support of parents and our Millbrae Community that we can continue to fund specific school needs, as well as additional staff for essential district-wide programs at all of our schools. Parent Teacher Associations (PTA s) Help fund school specific materials and programs. Materials and programs include: Classroom supplies Technology Field Trips Newsletters Assemblies Art programs and supplies Teacher Appreciation School-based events Millbrae Education Foundation (MEF) Helps fund district-wide programs and teaching personnel. During the school year, the MEF funded: A full-time Music Teacher for all elementary schools to participate and experience music education and a.4 FTE teacher for 5 th Grade Band. Two (2) Technology Specialists in moving our District closer to 21 st century learning skills and preparing for the Common Core and new assessments Additional staff development in technology for staff For more information on how you can support your PTA and the MEF visit: Millbrae Education Foundation: Green Hills Elementary PTA: Lomita Park Elementary PTA: Meadows Elementary PTA: Spring Valley Elementary PTA: Taylor Elementary PTA: https://www.millbraeeducationfoundation.org https://sites.google.com/site/taylormiddleschoolpta/ Thank you, in advance for your support and participation in our PTA and MEF, together we will continue to make a great difference in the lives of students! Sincerely, Linda Chin Luna, Superintendent

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