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SCV Home Study
Re-Enrollment Packet Check List
2015-16
All RETURNING AEA students MUST submit the following completed forms:
___ Enrollment Information
___ Emergency Contact Form
___ Health Information Form
COMPLETED FORMS MUST BE RECEIVED BY MAY 15th, 2015 IN ORDER TO ENSURE
YOUR CHILD’S ENROLLMENT FOR 2015-16.
Please mail completed forms to:
AEA SCV Home Study
Attention: Admissions
25443 Orchard Village Road
Valencia, CA 91355
Please contact the Home Study Office Manager if you have any questions: 661-6079297.
SCV HOME STUDY
RE-ENROLLMENT APPLICATION: SCHOOL YEAR 2015-2016
STUDENT INFORMATION
LEGAL NAME (LAST, FIRST, MIDDLE)
STREET ADDRESS
CITY
ZIP CODE
HOME PHONE NUMBER + AREA CODE:
DATE OF BIRTH (MM/DD/YY)
ENTERING WHAT GRADE (Fall 2015)
Circle: K 1
STUDENT LIVES WITH:
 MOTHER
 FATHER
 In a Single Family Permanent Residence
 BOTH
 Doubled up
(house, apt, condo, mobile home )
2
3
4
5 6
 OTHER
 In a foster home
(sharing housing with another  Unsheltered (car/campsite)
 In a shelter or transitional housing program
family)
 In a motel/hotel
 Other (Please specify)
 In a Licensed Child Institution
PARENT / LEGAL GUARDIAN (1)
NAME (LAST, FIRST, MIDDLE)
RELATIONSHIP TO STUDENT
STREET ADDRESS
CITY
ZIP CODE
HOME PHONE NUMBER + AREA CODE
WORK PHONE NUMBER + AREA CODE
CELL PHONE + AREA CODE
EMAIL ADDRESS:
PARENT/ LEGAL GUARDIAN (2)
NAME (LAST, FIRST, MIDDLE)
RELATIONSHIP TO STUDENT
STREET ADDRESS
CITY
ZIP CODE
HOME PHONE NUMBER + AREA CODE
WORK PHONE NUMBER + AREA CODE
CELL PHONE + AREA CODE
EMAIL ADDRESS:
I/WE HAVE REVIEWED THE RE-ENROLLMENT FORM AND TO THE BEST OF MY/OUR KNOWLEDGE, THE INFORMATION
THAT HAS BEEN PROVIDED IS TRUE AND COMPLETE. I UNDERSTAND THAT GIVING FALSE
OR INCOMPLETE INFORMATION REQUESTED HEREIN WILL RISK OR DELAY IN THE PROCESSING OF THE ABOVE NAMED
STUDENT'S ENROLLMENT AND MAY JEOPARDIZE ENROLLMENT AT ANYTIME AT THE ALBERT EINSTEIN ACADEMY.
NAME OF PARENT / GUARDIAN (PRINTED):
RELATIONSHIP TO STUDENT:
SIGNATURE OF PARENT / GUARDIAN:
DATE
SCV Home Study
Emergency Contact & Medical Authorization
__________________________________________________________________________________
Student’s Last Name
First Name
Grade in 2015-16
__________________________________________________________________________________
Student’s Home Address (Street) (City) (Zip)
__________________________________________________________________________________
Student’s Home Phone
Student’s Birthdate
__________________________________________________________________________________
Parent/Guardian 1 Name
Relationship (Mother, Father, etc...)
Daytime Phone
__________________________________________________________________________________
Parent/Guardian 2 Name
Relationship (Mother, Father, etc...)
Daytime Phone
Please List Three Emergency Contacts:
__________________________________________________________________________________
Emergency Contact Name
Relationship To Student
Daytime Phone
__________________________________________________________________________________
Emergency Contact Name
Relationship To Student
Daytime Phone
__________________________________________________________________________________
Emergency Contact Name
Relationship To Student
Daytime Phone
I hereby GIVE consent for the following medical care providers and hospitals to be called:
__________________________________________________________________________________
Physician’s Name
Phone
Dentist’s Name
Phone
__________________________________________________________________________________
Medical Specialist’s Name
Specialty
Phone
History Please list any important facts about the child’s medical history that may require special attention by school personnel,
including allergies, medications being taken, and any physical impairment to which a physician should be alerted.
_______________________________________________________________________________________
In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any
treatment deemed necessary by above named doctors, or, in the event the designated preferred practitioner is not available, by
another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible. This authorization does
NOT cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for
such surgery, are obtained prior to the performance of such surgery.
__________________________________________________________________________________
Parent/Guardian Name (printed)
Signature of Parent/Guardian
Date
Health Information Form 2015-2016
Student’s Name___________________________________________________________________________________________________________
Last
First
Middle
Student’s date of birth ____/____/_______
Gender_________ State and Country of Birth_________________________________________
Student’s address___________________________________________City____________________State_____________Zip___________________
Name of Legal Guardian #1___________________________________Phone______________________Work/Cell___________________________
Email Address______________________________________________
Name of Legal Guardian #2___________________________________Phone_______________________Work/Cell__________________________
Email Address_____________________________________________
Emergency Contact_________________________________________ Phone______________________ Work/Cell_________________________
Email Address_____________________________________________
Pediatrician/Primary Care Doctor______________________________ Phone_______________________ Date of last appointment______________
Specialist_________________________________________________ Phone_______________________ Date of last appointment______________
Dentist__________________________________________________ Phone_______________________ Date of last appointment______________
Condition
Yes
Comment
Condition
Allergies
*Please indicate mild, moderate, or severe in
the comments section
Diabetes
Asthma or breathing problems
*Please indicate mild, moderate, or severe in
the comments section
Head Injury; concussion
Attention-Deficit/Hyperactivity Disorder
Hearing problems or deafness
Behavioral problems
Heart problems
Cancer
Muscle problems
Developmental problems
Seizures
Bladder problems
Sickle Cell Disease
Bleeding problems
Speech problems
Bowel problems
Spinal Injury
Cerebral Palsy
Surgery
Cystic Fibrosis
Vision problems
Dental problems
Other
Yes
Comment
Describe any other health-related information about your child (for example, feeding tube, hospitalizations, hearing aids, assistive devices, braces)
________________________________________________________________________________________________________________________
List all prescription, over-the-counter, and herbal medications your child takes regularly_________________________________________________
Is medication required during school hours? ⏩ Yes ⏩ No If Yes, medication name and reason for taking
________________________________________________________________________________________________________________________
Check here if you want to discuss confidential health information with the school nurse or other school authority ⏩ Yes ⏩ No
⏩ Yes ⏩ No Consent to contact doctor: The school nurse has permission to contact my child’s doctor if medically necessary.
I understand that the school needs to be informed of any health or medical conditions that may affect my child’s school day or impact their learning.
I also understand that the school nurse may need to share information about my child’s condition with appropriate school staff. If I do not wish that
information shared I must request this in writing and file it with the school nurse.
________________________________________________________________________________________________________________________
Parent/Guardian Signature
Parent/Guardian Name (printed)
Date