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
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