How to Enroll your Child at Holly Drive Leadership Academy

How to Enroll your Child at Holly Drive Leadership Academy
Who needs to register?

Returning students

New students
What are the requirements?
All students must be registered by a parent and provide the documents outlined below.

All students
Must bring in proof of residency (Can include items such as a utility bill, rental agreement,
mortgage document, or military housing orders).

Proof of immunizations against polio, measles, mumps, and rubella (MMR), diphtheria, whooping
cough, and tetanus.

Proof of immunization against chickenpox OR Proof of having had chickenpox.

Last Report Card
Kindergarten & First Grade Students

Children must be five years old on or before December 2, 2013, in order to be eligible to attend
Kindergarten.

Copy of a birth certificate

Proof of vaccination against hepatitis B and chickenpox.
All first grade students

Proof of recent physical examination

Must be at least 6 years old by December 2, 2013.
Completion of this application does NOT guarantee enrollment.
You will be notified if your child has been accepted to our academy.
All sections of this application must be completed to be considered for enrollment.
We thank you for your interest in Holly Drive Leadership Academy
Holly Drive Leadership Academy
4801 Elm Street  San Diego, CA 92102
(619) 266-7333  (619) 266-2540 fax
Please make sure you have attached a copy of the following items:
1.) Verification of address
2.) Student’s Birth Certificate
3.) Yellow Immunization Card
4.) Health Check Up For School Entry
5.) Last Report Card
Completion of this application does NOT guarantee enrollment.
You will be notified if your child has been accepted to our academy.
All sections of this application must be completed to be considered for enrollment.
We thank you for your interest in Holly Drive Leadership Academy
Mission Statement
The mission of the charter school is to establish a child-centered community and learning environment that
will assist students in understanding the purposes and value of the school experience. In doing so, we hope
to inspire students to develop a personal sense of ownership and appreciation for the great potential they
have and the role that schooling plays in developing and realizing that potential. The student goals of the
school are to provide and create within students:
Leadership via an understanding of self and the society in which we live
An understanding of business principles and its relationship to serving others
Academic excellence in core subjects
Technological competence
An understanding of and appreciation for the fine arts
Help student develop good character
The school aims to develop in its students a dedication to community service and the motivation and skills
necessary for continuous successful life-long learning.
HOLLY DRIVE LEADERSHIP ACADEMY
Directions for Completing the PK-12 Enrollment Form
When completing a blank form please complete the Holly Drive Leadership Academy PK-12 Enrollment Form by
printing using black or blue ink. Complete each box in Sections I-III and sign the form on p.2. Note that verification
is needed for the information you provide in Boxes 3 and 14 for a new enrollment at the school.
If completing a pre-filled form please note that information on this form in Sections I-III reflects responses in a
previous enrollment form received from you. Please make corrections to Sections I-III, sign and date the back of
the form (even if no corrections are needed), and return to your child's school.
SECTION I: Student Information
Boxes 1-2.
These are for OFFICE use ONLY. Do not enter any information in these boxes.
Box 3. Legal Name
Box 4. Nickname
Box 5. Other Name(s) used previously
Enter your child‟s Legal Name (as printed on the birth certificate or other legal
document): Last Name, First Name, Middle Name/Initial, and Suffix (Jr, II, III).
NOTE: The child‟s legal name and birthdate must be verified by the office staff.
Forms of verification include a birth certificate, affidavit, church records, or
passport.
Enter a name that your child uses if he/she does not use the Legal Name in Box 3.
Example: A child named Eleanor might use the nickname Ellie.
Enter a name that your child may have used or is known by that is different than
the Legal Name in Box 3. Examples include a former legal name or a maiden name.
Box 6. Birth date
Enter your child‟s birthdate using mm/dd/yyyy.
Box 7. Student Social Security Number
Enter your CHILD‟S Social Security Number (optional) or if no number, leave blank.
Box 8. Gender
Check either Male (M) or Female (F).
Box 9. Hispanic/Latino Ethnicity
Check a single box indicating „Yes‟ or „No‟ if child is Hispanic or Latino.
Select one or more race categories from listed races.
Box 10. Race
(See “RACE/ETHNIC DEFINITIONS FOR PK-12 ENROLLMENT CARD”.)
Box 11. Release of information
Check „Opt Out‟ only if you do not want addresses and phone numbers of student
released to school organizations or groups.
Box 12. Student email
Enter your CHILD‟S email address (optional). If no email address, leave blank.
Box 13.
This is for OFFICE use ONLY. Do not enter any information in this box.
Box 14. Household Address
Enter the address where the child lives including the city, state, and zip code.
If you are living somewhere temporary due to financial hardship you may use your
school‟s address as a household address.
Box 15. Home Phone
Enter the phone number where the child lives. Include the area code.
Box 16. Mailing Address
If you receive mail at an address other than the household address in Box 14, enter
that address here.
Box 17. City and State of Birth
Enter the city and state where your child was born.
Box 18. Country of Birth
Enter the country where your child was born.
Box 19. First enrolled in a California
school (K-12)
Box 20. First enrolled in a U.S. school
(K-12)
Enter the date that your child was first enrolled in a California school for Grades K12. If your child is entering Kindergarten, enter the first day of school.
Enter the date that your child was first enrolled in a U.S. school for Grades K-12. If
your child is entering Kindergarten, enter the first day of school.
Check ONE box that best describes where the child lives. If your residence is
temporary due to financial hardship (“doubling up” by living with friends or family,
living in a temporary shelter, hotel, motel or living as unsheltered) check the
homelessness box that best describes your current situation.
Box 21. Student Residential Status
Directions for Completing the Holly Drive Leadership Academy PK-12 Enrollment Form ● Page 1 of 2 (draft 3/4/2011)
Box 22. School Age Siblings
If you have other children that currently attend (or will be attending this school
year) any San Diego Unified Schools in Grades K-12 enter their full name, grade,
and school name. If you need to list additional names, use the Notes/Additional
Information box in Section IV.
PART II: Contact Information
Box 23.
Contact Information
Enter information for the parent/guardian to provide contact information for the school. This is the
primary contact.

Contact full name: Enter your full name.

Relationship: Enter your relationship to the child (Mother, Father, Legal Guardian, Step
Parent, Agency Representative, Brother or Sister, Brother/Sister-in-law, Cousin, Emancipated
Minor, Father/Mother-in-law, Friend, Grandparent, Law Officer, etc.).

Lives with student?: Check „Yes‟ or „No‟. If your address is different than the child‟s
household address entered in Box 14, write it here.

Home, Work, Cell phones: Enter your home, work and cell (optional) numbers. Include any
extensions, if necessary.

E-Mail Address: Enter your home e-mail address (optional). You will be asked about this by a
school staff member.

Employer: Enter the name of your employer or business.

Active duty military: Check „Yes‟ or „No‟.

Contact Primary Language: Enter YOUR primary language.

Education Level: Check the highest level of education you completed in any school. Check
only one.
- Not a high school graduate
- High school graduate
- Some college/AA Degree
- College graduate
- Graduate school/post-graduate
- Decline to state

Additional Information: Check all that apply..
- Interpreter required: You will need an interpreter to communicate with the school and your
child‟s teachers.
- Parent online access: You would like to be able to view your child‟s attendance and grade
information online using ParentConnection (if the school offers this service) and Naviance
for middle/high school families
Box 24.
Other Contact
Enter information for another parent, step-parent, or guardian to provide contact information to the
school. Complete the sections like Box 23.
 Additional Information: Check all that apply to the listed Other Contact.
- This contact needs a copy of the child‟s report card.*
- This contact needs a copy of the child‟s progress report.*
- Interpreter required (see box 23 above).
- Parent online access (see box 23 above).
* Note: By default, the contact named in box 23 above receives this.
Box 25.
Emergency Contacts
Enter information for one or two emergency contacts that can be reached by phone in case the
parent/guardians cannot be reached. Provide the contact‟s full name, relationship to child, phone
numbers, and primary language. NOTE: If you need to enter additional contacts, use the
Notes/Additional Information box in Section IV.

Additional Information: Check all that apply to the listed Emergency Contacts.
- Interpreter required (see box 23 above)
- OK to release student: The school is authorized to release the child to the emergency contact.
SECTION III: Questions for Parent/Guardian
Boxes 26-31.
Please complete Questions 26-31.
Signature and Date
You must sign and date this form.
SECTION IV: District Administrative Information—FOR OFFICE USE ONLY
Boxes 32-43
These are for OFFICE use ONLY (unless you use the Notes/Additional Information section to list
additional information from Sections I or II).
Directions for Completing the Holly Drive Leadership Academy PK-12 Enrollment Form ● Page 2 of 2 (draft 3/4/2011)
RACE/ETHNIC DEFINITIONS FOR PK-12 ENROLLMENT CARD
On the PK-12 Enrollment Card there is the addition of Question #9 and a change to Question
#10. Use the descriptions below to assist in completing the form.
Question #9: A “yes” or “no” response is required.
Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other
Spanish culture or origin, regardless of race.
Question #10: Select one or more race categories from the following options ~
Race Definitions:
American Indian or Alaska Native: A person having origins in any of the original peoples of North
and South America (including Central America), and who maintains a tribal affiliation or community
attachment.
Asian Indian: A person having origins in any of the original peoples of India.
Black or African American: A person having origins in any of the black racial groups of Africa.
Cambodian: A person having origins in any of the original peoples of Cambodia.
Chinese: A person having origins in any of the original peoples of one of the following countries:
(Mainland) China, Taiwan, Hong Kong.
Filipino: A person having origins in any of the original peoples of the Philippine Islands.
Guamanian: A person having origins in any of the original peoples of Guam.
Hawaiian: A person having origins in any of the original peoples of Hawaii.
Hmong: A person having origins in any of the original peoples of Laos and are of the Hmong culture or
origin.
Japanese: A person having origins in any of the original peoples of Japan.
Korean: A person having origins in any of the original peoples of Korea.
Laotian: A person having origins in any of the original peoples of Laos.
Other Asian: A person having origins in any of the original peoples of one of the following: Burma,
Malaya, Thailand, Indonesia, Sri Lanka, Mien, Singapore, Bangladesh, Bhutan, Nepal, Pakistan, or any
other Asian country not listed.
Other Pacific Islander: A person having origins in any of the original peoples of the Pacific Islands
other than Hawaii, Guam, Samoa (American Samoa or Western Samoa) or Tahiti. Includes islands such
as Polynesia, Fiji Islands, Marshall Island, Melanesia, Palau, Tonga, Truk, or Yap.
Samoan: A person having origins in any of the original peoples in Samoa (American Samoa or Western
Samoa).
Tahitian: A person having origins in any of the original peoples of Tahiti.
Vietnamese: A person having origins in any of the original peoples of Vietnam.
White: A person having origins in any of the original peoples of Europe, the Middle East, or North
Africa.
4.2.10 Enrollment Options
OFFICE ONLY
Student Name:
Grade:
Teacher:
Room #:
HOLLY DRIVE LEADERSHIP ACADEMY
PK-12 ENROLLMENT FORM 2013-14
Complete Sections I-III and sign page 2. Section IV must be completed by office staff. Please print legibly using black or blue pen.
For full directions, please refer to Completing Your Child’s Enrollment Form available at www.sandi.net/enrollment.
OFFICE ONLY
1.Student District ID:
2. Student State ID (SSID):
I. STUDENT INFORMATION
3. Last name (LEGAL NAME ONLY)
4. Nickname:
First
Middle
5. Other name(s) used previously (AKA):
6. Birth date:
/
8. Gender
7. Social Security Number (optional):
/
--
9. Is student Hispanic
or Latino?
10. Race (select one or more):
 Black or African American  White
 Cambodian
 Japanese
 Laotian
 Vietnamese
 Asian Indian
 Guamanian
 Hawaiian
M F
 Yes
 No
 Other Asian
 Other Pacific Islander
11. Your address /phone number may be shared with District-approved school-related organizations that
are authorized to receive this directory-type information. If you do not want your information to be
shared, you must select ‘Opt Out’.
 Opt Out
OFFICE ONLY
13. Date:
/
Address Verified
--
 Chinese
 Filipino
 American Indian or Alaska Native
 Hmong
 Korean
 Tahitian
 Samoan
12. Student email address (optional):
14. Household address:
City, State:
ZIP Code:
16. Mailing address (if different from household):
City, State:
ZIP Code:
/
15. Home phone
(
Suffix (Jr, II, III)
)
17. City, State of birth:
18. Country of birth:
21. Student residential status (check one):
 Foster Group Home (FGH) (FFA)
 Homelessness-hotel/motel*
 Hospital (not state hospital)
 Other




19. First enrolled in a CA 20. First enrolled in a US
school (K-12):
school (K-12):
Date:
/
/
Date:
/
/
Parent/legal guardian (home)
 Foster Family Home (FFH)
Homelessness-doubling up (living with someone)*
Homelessness-sheltered*
 Homelessness-unsheltered*
Foreign exchange student
 Residential facility
*Temporary residence due to financial hardship
22. Only if applicable complete and include siblings who are currently in Grades PK-12 in SDUSD.
Sibling 1 full name:
Grade:
School name:
Sibling 2 full name:
Grade:
School name:
Sibling 3 full name:
Grade:
School name:
II. CONTACT INFORMATION
Contact full name
Provide at least three contacts—if additional space is needed use Notes on back of form.
23. CONTACT
24. OTHER CONTACT
25. EMERGENCY CONTACTS
(OTHER THAN PARENTS)
Full name:
Relationship to student
Lives with student?
Yes 
No 
If no, provide address here:
Yes 
No 
If no, provide address here:
Relationship to student:
Home phone (
)
Work phone (
)
Home phone
(
)
(
)
Cell Phone (
)
Work phone
(
)
(
)
Cell phone
(
)
(
)
 Interpreter required
 OK to release student
Full name:
Email address (optional)
Employer
Active duty military
Yes 
No 
Yes 
No 
Relationship to student:
Contact primary language
Education level
(select one)
Select one or more for each
contact.
 Not a High School Graduate
 High School Graduate
 Some College/AA Degree
 College Graduate
 Graduate School/Post-Graduate
 Decline to state
 Interpreter required
 Parent online access
 Not a High School Graduate
 High School Graduate
 Some College/AA Degree
 College Graduate
 Graduate School/Post-Graduate
 Decline to state
 Report card
 Progress report
 Interpreter required
 Parent online access
SIGNATURE REQUIRED ON REVERSE
Home phone (
Work phone (
Cell phone (
)
)
)
 Interpreter required
 OK to release student
OFFICE ONLY Student Name: _____________________________________________ Grade:________ Teacher: ____________________________ Room #: _________
OFFICE ONLY
III. QUESTIONS FOR PARENT/GUARDIAN
The following questions provide important information for the school staff. Parents must answer the following questions. Check ‘Yes’ or ‘No’ for each
question where appropriate. Questions 29 and 30 are for high school students only. Question number 29 requires that you check ‘Opt Out’ or leave it
blank if you agree to release your child’s information.
26. Has your child ever received Special Education
services?
 Yes  No
28. Name, city, and state of last school attended:
27. Are you now engaged in migrant work, or have you been
engaged in migrant work (moved and worked seasonally in
agricultural, lumber or fishery related jobs) in the last three years?
 Yes  No
29. (For high school students only) Federal law requires release
of student information to military recruiters. If you do NOT want
this information released for your child, you must select ‘opt out’.
http://www2.ed.gov/policy/gen/guid/fpco/hottopics/ht-10-0902a.html
 Opt Out
31. (For students born outside the U.S.–see #18) Was this
student born in a foreign country to diplomatic, military personnel or
other U.S. citizen and granted U.S. citizenship?
 Yes  No
Last grade level completed:
30. (For high school students only) Has your
child ever played interscholastic athletics?
 Yes  No
The information provided in Sections I-III is true to the best of my knowledge.

Parent/Guardian signature (required)
Date
IV. DISTRICT ADMINISTRATIVE INFORMATION – FOR OFFICE USE ONLY
32. Address verification document:
LEGAL BINDINGS
33. Birth verification documents:
 Birth certificate
 Affidavit
 Passport
 School records
 Church records
 Unverified
34. School of residence:
35. District of residence:
 Interdistrict attendance permit  InterSELPA agreement
36. Boundary exception for non-resident student
Type:
Reason:
ENTRY INFORMATION
NOTES/ADDITIONAL INFORMATION
37. Previously enrolled in SDUSD?  Yes*  No
*If Yes: Last year
School
38. Entry date:
/
Grade
/
39. Entry reason (check one):
 Enter from within SDUSD  Enter from Out of District
 Enter from Out of State
 Initial Enrollment K-12
 Enter from Charter School within SDUSD
40. For students new to SDUSD entering from within California:
Student State ID (SSID) (if known):
Previous CA district:
Previous CA school name:
41. For students new to SDUSD entering from outside of California:
Previous school:
City, State:
EXIT INFORMATION
42. Exit date:
/
IMMUNIZATIONS
/
43. Exit reason (check one):
 Grades PK-6 transfer within SDUSD
 Grades 7-12 transfer within SDUSD
 No Show-Enrollment Dropped
 Other:
44a. Immunization status:
 Complete  Incomplete  Exempt
 Grades PK-6 transfer out of SDUSD
 Grades 7-12 transfer out of SDUSD
 Withdrew Grades PK-6
44b. Dental Exam (K only)?  Yes  No
HOLLY DRIVE LEADERSHIP ACADEMY PK-12 ENROLLMENT FORM 2013-14 (Revised 3.2.11)
NOTES:
OFFICE USE ONLY
TCHR/CNSLR
SIS ID#
MO____DY_____YR_______
EFFECTIVE ENTER DATE
Holly Drive Leadership Academy
4801 Elm Street  San Diego, CA 92102
(619) 266-7333  (619) 266-2540 fax
SASI ID#
ENTER CODE
ADDRESS VERIFIED:
SEC/SAP
BIRTHDATE VERIFIED BY:
BIRTH CERTIFICATE______
CHURCH RECORDS ______
OTHER________________________
DROP CODE
ETHNIC CODE
ROOM(S)
RES LOC
RECORDS REQ’D
RECORDS REC’D
IMMUN STATUS
DROP DATE
LANG CODE
ELPL
SPC
PHC
STUDENT INFORMATION FORM K-12
Student Information
Student’s Legal Name:
(Last)
Date of Birth:
Current Address:
Sex:
(First)
(Middle)
(Called)
Social Security Number:
( Street)
(City)
Grade:
(Zip)
(Home Phone)
Parent Information
 Parent  Guardian  Other
Name:
Address:
Employer:
Home Phone:
Pager #:
Work Phone:
Fax #:
Cell Phone:
Email:
Work Phone:
Fax #:
Cell Phone:
Email:
 Parent  Guardian  Other
Name:
Address:
Employer:
Home Phone:
Pager #:
Person to call if parent not available (Required for emergency)
Name:
Address:
Home Phone:
Work Phone:
Name:
Address:
Home Phone:
Work Phone:
Academic Information
School Name:
Address:
( Street)
Relationship to Student:
Cell Phone:
Relationship to Student:
Cell Phone:
Grade:
(City)
Has Student Been Enrolled in a San Diego City School Prior to this year?
School Name:
(Zip)
YES
NO
Student’s Birthplace: City
State or Country:
If Student’s Birthdate is other than the U.S., What is the date of first enrollment in a U.S.
School (Either Public or Private)?
Month
Year
The address I have provided is my correct residence. I declare under penalty of perjury under the laws of the State of California that
the foregoing is true and correct.
Signature
Date
IMPORTANT: KINDERGARTEN PARENTS!
◊
We need to know if your child went to preschool, and where, for your child’s records.
My child,
went to preschool at
Name of school:
Address:
City/State/ZIP:
Or
My child,
did not go to preschool.
Holly Drive Leadership Academy
4801 Elm Street  San Diego, CA 92102
(619) 266-7333  (619) 266-2540 fax
Verification of Residency
I, the undersigned, verify that the information I have provided Holly Drive Leadership Academy regarding
my place of residence is truthful and accurate. The address I have provided is my primary residence and the
primary residence of my child/children. I understand that if I have falsified any other information regarding
the fact that I reside in the attendance area of the Holly Drive Leadership Academy, I will be asked to enroll
my child/children in the appropriate school.
Student’s Name:
Address:
Parent’s Signature:
Please complete three sentences that best describe your child.
1.
2.
3.
Disciplinary History
During the last school year, my child received:
Referrals
___ No Referrals
___ 1-3 Referrals
___ 4-6 Referrals
Suspensions
___ No Suspensions
___ 1-2 Suspensions
___ 3-5 Suspensions
Completing this application does not guarantee acceptance into the school
Home Language Assessment Survey
Date
Fecha
Petsa
School
Escuela
Paaralan
Please answer the following questions.
Favor de contestar las siguientes preguntas.
Pakisuyong sagutin ang mga sumusunod na tanong.
1. Name of student
Nombre del alumno
Last
First
Middle
Grade
Birth Date
Apellido
Primero
Segundo
Grado
Fecha de Nacimiento
Una
Apelyido ng Ina
Baytang Kapanganakan
Pangalan ng mag-aaral Apelyido
2. Which language did your son or daughter learn when he or she first began to talk?
- Cuando su hijo o hija empezó a hablar - ¿cuál idioma aprendió primero?
- Aling wika ang natutuhan ng iyong anak simula ng siya ay matutong magsalita?
3. What language does your son or daughter most frequently use with adults in the
home?
- ¿Cuál idioma usa principalmente su hijo o hija cuando conversa con adultos de su casa?
- Anong wika ang pinaka-malimit na sinasalita ng iyong anak sa mga nakatatandang
kasama sa tahanan?
4. Which language is used most frequently by the adults in your home?
- ¿Cuál idioma usan los adultos de su casa con más frecuencia cuando conversan entre
ellos mismos?
- Aling wika ang pinaka-malimit gamitin ng mga nakatatanda sa inyong tahanan?
5. What language do you use most frequently to speak to your son or daughter?
- ¿Cuál idioma usa Ud. con más frecuencia cuando habla con su hijo o hija?
- Anong wika ang pinaka-malimit mong sinasalita sa iyong anak?
Signature of parent or guardian
Firma del padre de familia o tutor
Lagda ng magulang o tagapangalaga
This information will be used by district and U.S. Office for Civil Rights to develop school programs.
-Esta información se usará por el distrito escolar y La Oficina de Derechos Civiles para desarrollar programas
escolares.
-Ang kabatirang ito ay gagamitin ng Distrito at ng Tanggapan ng Pamamahala ng Karapatan ng Mga Mamamayan sa
pagbabalangka ng mga gawaing pampaaralan.
Student Name ________________________________________
The district is required by state and federal law to report the racial/ethnic make-up of students attending our schools. This is not done by
individual student. It is done by reporting numbers in each representative group. At this time the district must report only one racial/ethnic
category per child.
A multiracial/multiethnic designation may be made after you have selected one ethnic group from those listed below. If you wish to designate
more than one racial/ethnic group for your child you may indicate this on the bottom of this form. The school and the district will maintain this
information in your child’s records.
Please select one required racial/ethnic designation for your child. This designation will, be used for state and federal reports.
__African American: Not of Hispanic origin: A person having origins in any of the black racial groups of Africa.
__Alaskan/Indian: A person having origins in any of the original peoples of North America, and who maintains cultural
identification through tribal affiliation or community recognition.
__Asian Indian: A person having origins in any of the original peoples of India.
__Cambodian: A person having origins in any of the original peoples of Cambodia.
__Chinese: A person having origins in any of the original people of one of the following countries: (Mainland) China, Taiwan,
and Hong Kong.
__Filipino: (not Asian, Indochinese, or Pacific Islander): A person having origins in any of the original peoples of the
Philippines Island.
__Guamanian: A person having origins in any of the original peoples of Guam.
__Hawaiian: A person having origins in any of the original peoples of Hawaii.
__Hispanic: A person having origins in any of the original peoples of Mexico, Puerto Rico, Cuba, Central or South American,
Spain, or other Spanish culture or origin, regardless of race.
__Hmong: A person having origins in any of the original peoples of Laos, and are of the Hmong culture or origin.
__Japanese: A person having origins in any of the original peoples of Japan.
__Korean: A person having origins in any of the original peoples of Korea.
__Laotian: (not Hmong) A person having origins in any of the original peoples of Laos.
__Other Asian: A person having origins in any of the original peoples of one of the following: Burma, Malaya, Thailand,
Indonesia, Salanka, Mien, Singapore, Bangladesh, Bhutan, Nepal, Pakistan, or any other Asian country not listed.
__Other Pacific Islander (other than those listed above) A person having origins in any of the original peoples of the Pacific
Islands other than Hawaii, Guam, Samoa (American Samoa or Western Samoa) Includes islands such as Polynesia, Fiji
Islands, Marshall Island, Melanesia, Palau, Truk, Yap, or Tahiti.
__Portuguese: A person having origins in any of the original peoples of Portugal.
__Samoan: A person having origins in any of the original peoples of Samoa.
__Vietnamese: A person having origins in any of the original peoples of Vietnam.
__While not of Hispanic origin (not Portuguese): A person having origins in any of the original people of Europe, North Africa,
or the Middle East.
__Multiracial/Multiethnic: A person having origins in more than one of any of the above categories. Please designate:
Parent signature ____________________________________Date_____________
Parent/Teacher/Pupil Compact
By signing this compact, I, _____________________, a parent of a Holly Drive Leadership Academy
student, agree to participate in the following school-organized Parent/Teacher Involvement Program. This
program will help me learn how to support my child’s education at his/her school and to encourage me to
participate in my child’s school. This compact means that I will participate in the following activities:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Monthly Workshops (taught by my child’s school educators and volunteers)
Classes may include: Parent-Child Tutorials, How to Support Child Learning at Home, Basic Math
Skills Made Fun, Reading to a Child, Basic Nutrition, How to Obtain Social Assistance, Healthy Child/
Healthy Families, School Updates, and Anger Management/Disciplinary Methods.
At Home Visits (by teachers and aides)
At Home visits, by appointment and as requested, may be conducted in my home. The purpose of these
visits is to allow one-on-one interaction with me (the parent) and my child’s teacher(s).
During these home visits, I may be taught ways that I can support my child’s learning programs at
home. I may also confidentially discuss issues that are a factor in my child’s learning effort.
Become a School Volunteer
I will become a volunteer at my child’s school as my schedule allows, which may include:
Chaperoning on field trips, volunteering to assist with school programs, and after-school
tutorials/activities.
Attend Parent/Teacher Nights
Homework Involvement
To ask my child if he/she has homework and help him/her complete assignments on time.
Read School Updates
Regular classroom and school reports will be sent home to keep parents informed of school activities
and educational efforts. I will read these reports and updates.
Attend School Activities and Recitals
I will attend as many school activities (including recitals, plays, sporting events) that my schedule
permits.
To Send My Child to School Each Day Ready to Learn
I will send my child to school each day ready to learn, which includes: fed a healthy breakfast and has
appropriate snacks and lunch ( if my child does not qualify for the school’s meal program), properly
clothed, well rested, and with necessary books and supplies (i.e. notebooks, pencils, etc.).
Other Activities
I will become involved with other activities as they are developed that help my child become a better
student and a better citizen.
By signing this compact, I state that I do so voluntarily and of my own free will.
Parent Name
Parent Signature
Address
Phone
City
State
Zip
Holly Drive Leadership Academy
4801 Elm Street  San Diego, CA 92102
(619) 266-7333  (619) 266-2540 fax
Code of Conduct Contract
Our goal is to work together to strengthen self-control and responsibility in our students in a positive school atmosphere.
Discipline is an essential part of meeting that goal. Parents, students and school personnel must
work together to maintain high standards of school citizenship.
I have received and will uphold Holly Drive Leadership Academy’s
“Code of Conduct Policy” as well as the Uniform Policy.
Parent Signature:
Student Signature:
In your child’s interest,
Student Expectations
1. We support and uphold Holly Drive Leadership Academy’s Uniform Policy.
This means:
Navy Blue Uniform pants (no jeans!), skirts, skorts, jumpers, or dresses
Solid white, light blue or navy shirts or blouses with collars.
Wearing Navy blue and white does NOT constitute being in uniform
Every Friday will be “Free Dress Day”
2. We take responsibility for learning.
This means:
We arrive at school on time.
We are prepared for class.
We demonstrate a serious and responsible attitude in daily work.
Homework is carefully and thoughtfully completed and on time.
3. We try to settle our differences in a peaceful manner.
This means:
We respect other people’s property and personal space.
We do not physically or verbally fight with other children.
We do not take anything that does not belong to us.
4. We follow the directions of adults in charge, the first time given.
This means:
We look at the speaker.
We do not talk back to teachers or adults in charge.
This includes substitutes and lunchroom supervisors.
5. We are sensitive to the needs and feelings of others.
This means:
We use appropriate language at all times.
We do not bully or tease other children.
6. We are expected to move safely through the school.
This means:
No playing around in the bathrooms or hallways.
No running in the lunchroom, hallways, or up and down stairs.
Our School Is Special
Let’s Keep It That Way!
Student Signature:
Keep your immunization records online!
Holly Drive Leadership Academy is using the SDIR to store immunization records on their students.
By using this system, the school can make sure that your children’s immunization records can be
easily located by a school nurse or health care provider when you change schools, doctors, or
during a disease outbreak, or natural disaster.
San Diego Regional Immunization Registry (SDIR), part of the California Immunization Registry
(CAIR) will enter immunization records into the centralized, secure, and confidential database.
Please return this completed form and a copy of the individual's immunization record to your school.
For more information, visit the SDIR Website at:
http://www.immunization-sd.org/sdir/about.html
or call the SDIR Help Desk at (619) 692-5656.
Please complete the information below. Fill out additional form(s) if submitting more than one
individual’s immunization record.
Please print clearly and include your phone number in case we need to call you!
SUBMITTER
STUDENT
Name:
Last Name:
Street Address:
First name:
City:
Date of Birth:
Zip Code:
Gender:
Email:
Fields below will help locate the
immunization record in the future:
Home Telephone:
Relationship to student:
□ Parent
□ Guardian
□ Other [Specify]
□ Mother’s maiden name:
□ Medicine record #
CAIR USE ONLY:
□ ENTERED IN SDIR
DATE:___/___/___
STAFF INITIALS_______
Signature of Parent/Guardian: ______________________________________________________
If you do not want to share the immunization record, please contact SDIR/CAIR at (619) 692-5656.
Note: Immunization records are only shared with public health, participating health care providers, schools, childcare
and other authorized programs that require the review of immunization records for enrollment.
HHSA: IZ148ES-SDUSD 05/09
Holly Drive Leadership Academy
4801 Elm Street  San Diego, CA 92102
Nursing & Wellness Program
Student Services Office
San Diego Immunization Registry
The County of San Diego Health and Human Services Agency operates the San Diego Regional Immunization
Registry (SDIR), part of the California Immunization Registry (CAIR). SDIR is a secure and confidential
web-based immunization information system which allows immunization records to be shared with a student’s
doctor, health plan provider, school, and/or childcare provider. Immunization records entered into the registry
identify vaccines that have been given or that are needed.
By filling out the attached form and returning it to your child’s school, your child’s immunization record will
be entered in SDIR. This allows the record to be easily located in situations such as:
 when you change doctors
 when your child changes schools or child care providers
 if you misplace or lose the record
 if there is a disease outbreak
 if there is a natural disaster
Once your child’s record is in the SDIR, you will also be able to access it online. Please go to
http://www.immunization-sd.org/sdir/docs/View-Your-Immunization-Records-Online.pdf for instructions.
For further information, you may visit the SDIR website at: www.immunization-sd.org/sdir/about.html or call
the SDIR Help Desk at (619) 692-5656.
HOLLY DRIVE LEADERSHIP ACADEMY School Year ____________
HEALTH INFORMATION EXCHANGE CONSENT
Child’s Name:
Birthdate:
Last
First
Middle
School:
Grade:
Month/Day/Year
SS#
State law requires that the parent inform the school if a child is receiving prescribed medication for a
continuing health problem.
Health Problem/Allergies:
Medication:
Dosage:
Physician's Name/Clinic:
Health Insurance Plan:
□ No Physician
□ No Health Plan
Telephone #:
(If Medi-Cal, Healthy Families, or another health plan, please write name of health plan)
□ My children do not have health insurance and I would like more information. Please release my name, address,
and telephone number to an authorized insurance enrollment worker.
Parent/Guardian Signature or
Authorized Representative of Minor Student
Parent/Guardian Name (print)
Date
PERMISSION FOR OVER-THE-COUNTER MEDICATIONS
Please check if you would like the school nurse, after assessment, to provide the following over-the-counter (OTC)
medications, if indicated: Advil, Motrin, or Tylenol to your child as appropriate:
Parent/Guardian Signature or
Authorized Representative of Minor Student
□ Yes □ No
Parent/Guardian Name (print)
Date
OTC medications may not be given by any unlicensed staff member except when a physician’s order is on file.
Phone No.: (
)
Area Code
(
Home
)
Area Code
(
Work
)
Area Code
PLEASE RETURN TOMORROW
This authorization expires at the end of each academic year and must be renewed annually.
07/20/05
PS #2059
Cell
Parent’s Guide to Immunization Requirements
According to the California School Immunization Law, children must have their required immunizations
(shots) before they can attend school or child care.
Here’s what you need to do:
1. Look at your child’s shot record
2. See if your child has the required shots. To find out, look at the schedule below:
If your child is this age:
He/she must have these shots:
2-3 months
1 each of DTP/DTaP, Polio, Hib, Hep B
4-5 months
2 each of DTP/DTaP, Polio, Hib, Hep B
6-14 months
3 DTP/DTaP
2 each of Polio, Hib, Hep B
15-17 months
3 each of DTP/DTaP, Polio
2 Hep B
At least 1 Hib given on or after the first birthday
1 MMR given on or after the first birthday
18 months-4 years
4 DTP/DTaP
3 each of Polio, Hep B
At least 1 Hib given on or after the first birthday
1 MMR; given on or after the first birthday
Kindergarten
5 DTP/DTaP*
4 Polio**
3 Hep B
2 MMR; both must be on or after the first birthday
7th Grade (Effective 7/1/99)
3 or more Td, DT, DTP or DTaP
4 Polio***
3 Hep
2 MMR; both must be on or after the first birthday
* If the fourth DTaP dose was given after the child’s fourth birthday, requirements are met
** If the third polio dose was given after the child’s fourth birthday, requirements are met.
*** If the third polio dose was given after the child’s second birthday, requirements are met.
3. If any shots are missing, take your child, along with this form, to his/her doctor or clinic before
registration. If your child needs more shots later in the year, he/she can attend school/child care
as long as the remaining shots are received when they become due.
4. Take your child’s up-to-date shot record to school/child care registration.
The California School Immunization Law allows a child to be exempt from the immunization requirements
for personal beliefs or medical reasons. Ask your school or child care provider for details.
County of San Diego - Health and Human Services Agency - Immunization Program
Holly Drive Health History
Name
(Last)
(First)
(Birthdate)
Grade
Room No.
School
INDICATE KNOWN HEALTH PROBLEMS. GIVE DATES AND EXPLAIN:
Asthma
Allergies
Diabetes
Heart problem
Kidney disease
Seizure disorder
Ear problem, hearing defect
Eye problem, glasses
Operations, fractures, head injury
Medications ( even if given at home)
Other health information
Indicate if the student has had the following diseases:
Chickenpox
Measles (10-day)
Rubella ( 3-day measles)
Mumps
Scarlet fever/strep infection
Whooping cough
Hepatitis
Meningitis
Other
IMMUNIZATION HISTORY AND RECORD
Date
Date
Date
Date
Date
Polio
Td
D.P.T.
Measles
Mumps
Rubella
Other
Immunization exemption
Reason:___________________________________
Tuberculosis contact in the family: YES___NO___
Skin Test ___________ X-Ray______________
Last physical examination
by
date
Last dental examination
Physician’s Name
by
date
Dentist’s Name
I verify that to the best of my knowledge my child is able to participate in all the regular school activities. If not, I
will bring a statement from the physician within two weeks stating that the following limitations are necessary:
Signature
Relationship
Date
County of San Diego
School Entry Health Checkups
(Kindergarten/First Grade)
You want your child to be healthy to get the most out of
school.
Early and regular health checkups can find, prevent and
treat many health problems before they become serious.
That is why California has a law that says all children
must have a health checkup before they enter first grade.
The health checkups must be completed a year and a half
(18 months) prior to or 90 days after your child begins
first grade to meet the school entry requirement.
A health checkup includes:
9 A health history and physical examination
9 Urine, blood and tuberculosis (TB) tests
when necessary
9 Dental screening
9 Nutritional assessment
9 Vision and hearing tests
9 Immunizations, if necessary
9 Developmental assessment
9 Other tests, if needed
To bring to your doctor or clinic:
1. The Report of Medical Examination for School
Entry (Green Form - attached). Please complete the
top part of the form filling in all of the information
requested from parent or guardian.
2. Your child's yellow Immunization Card
(called the California Immunization Record).
If you do not have this card, ask for one where your
child had the last immunizations.
3. A Benefits Identification Card (BIC).
Bring this if your child has Medi-Cal.
After the health checkup:
1. Give the Report of Medical Examination for
School Entry to the school.
2. Show the Immunization Card to the school.
Then take the card home and keep it in a safe place.
You will need proof of immunizations many other
times in your child's life.
Healthy
children get
the most out
of school!
Before first grade begins:
If your child had a health checkup at kindergarten entry
and a report is not already at the school, you need to get a
report from your child's doctor or clinic and take it to the
school where your child will begin first grade.
If you are not able to pay for this checkup, please call
Maternal, Child and Family Health Services to find out if
your child is eligible for a no-cost health checkup through
the CHDP* (Child Health and Disability Prevention)
Program and for on-going complete medical, dental and
vision care at a price you can afford.
Note . . .
PLEASE CALL TODAY
1-800-675-2229
English and Spanish spoken
*CHDP is a state program that pays for health checkups and
immunizations for children from low-income families and children on
Medi-Cal.
DHS:PHE-P80 ES (7/06)
If health checkups or immunizations are against your
personal beliefs, you must sign a form at the school office.
If your child cannot receive immunizations because of a
medical problem, bring a doctor's note to the school.
If there is a disease outbreak at the school and your child
is not immunized against the disease, your child cannot
attend school until the outbreak is over.
County of San Diego Health and Human Services Agency
P.O. Box 85222, San Diego, CA 92186-5222
(Español al dorso)
Holly Drive Leadership Academy
Nursing and Wellness Program
IMPORTANT INFORMATION FOR PARENTS OF
KINDERGARTEN AND FIRST GRADE STUDENTS
Dear Parent:
CALIFORNIA STATE LAW REQUIRES THAT ALL CHILDREN ENTERING FIRST
GRADE HAVE A COMPLETE PHYSICAL EXAM.
There is now a mandatory exclusion policy for those children who do not meet this requirement within 91
days of first grade entry. The Child Health and Disability Prevention (CHDP) Program offers this exam at no
cost to eligible children in the community.
Please check the square below to tell us how you plan to meet the requirement of the Child Health and
Disability Prevention Program, and return this form to the school nurse.

1. I will take my child to my personal physician. (I will have my physician complete the attached
Report of Health Check-Up and return it to the school nurse.)

2. I belong to a health maintenance organization (such as Kaiser, CHG, PHP) and will have my child
examined there. (I will have the attached Report of Health Check-Up completed and will return
it to the school nurse.)

3. My child does not have medical insurance and I would like to have an exam at school. (I will sign
and fill out the attached CHDP Eligibility Information form, and return it to the school nurse.)

4. My child already had a health check-up within 18 months before date of entry to first grade. I will
send a copy of the physical exam to the school nurse. (Attached report form may be used for this
purpose.)
Child’s Name
Parent/Guardian Signature
Work Phone No.
RETURN TO SCHOOL NURSE - TOMMOROW
CHDP
Home Phone No.
County of San Diego
Child Health and Disability Prevention (CHDP) Program
Report of Medical Examination for School Entry
California law requires a medical examination for school entry to protect the health of all children.
Please return this report to the school. All personal information will be kept confidential.
PART I TO BE FILLED OUT BY PARENT OR GUARDIAN/ Español al dorso
CHILD’S NAME—Last
First
Middle Initial
School
ADDRESS—Number, Street
City
ZIP Code
Birth Date—Month/Day/Year
… I want the medical provider to complete Part II and Part III
… I want the medical provider to complete Part II only
_____________________________________/____________
Signature of Parent or Guardian
Date
PART II TO BE FILLED OUT BY THE MEDICAL PROVIDER
Tests and Evaluations
Child’s Height
Child’s BMI
Percentile
Child’s Weight
inches
lbs
Health/Development History
Medical Provider Information
Name, Address, and Telephone Number:
Date
ozs
%
Physical Examination
Nutritional Evaluation
Vision Screening
Audiometric Screening
Blood Test for Anemia
Urine Dipstick
/
Dental Screening
Tuberculin (TB) Skin Test (Recommended for ALL children entering first grade)
Signature of Medical Professional
CHILD HAS A COMPLETED OR UPDATED YELLOW CALIFORNIA IMMUNIZATION RECORD
Date
† YES † NO
PART III TO BE FILLED OUT BY THE MEDICAL PROVIDER
Other Health Information (Optional): For the child’s welfare—and with the permission of the parent or guardian—it is
recommended that significant health information be shared with the school. Please contact the school nurse if the child needs help
with medication at school.
† Parent requests Part III not be filled out † The examination revealed no conditions of importance to school or physical activity.
† Conditions that need further evaluation or that can affect school or physical activity are (please explain):
WAIVER OF MEDICAL EXAMINATION
Note: Your child must have immunizations required by State law, even if no health examination is given.
I have been told about the medical examination recommended by health professionals and required by State law. I have also
been told where and how my child can receive medical examinations at no cost, if such assistance is needed.
___ I do not want my child to receive a medical examination
___ I do want my child to receive a medical examination, but I am unable to get it because _________________________
____________________________________________________________________________________________________
/
Signature of Parent or Guardian
Date
County of San Diego Health and Human Services Agency, 3851 Rosecrans Street, Suite 522, MS: P511-H, San Diego, CA 92110
For more information, please call 619-692-8808
MCFHS-77 ES 4/08