Fillable 2021-22 STUDENT INFORMATION CARD (San Luis Coastal Unified School District)

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2021-22 STUDENT INFORMATION CARD (San Luis Coastal Unified School District)

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Student’s Name (First/Last): ___________________________________________
Teacher (Elem): ______________________________________________________
SAN LUIS COASTAL UNIFIED SCHOOL DISTRICT
2021-22 STUDENT INFORMATION CARD
Counselor (Middle/High): ______________________________________________
School: ______________________________________ Grade: ___________
STUDENT ENROLLMENT STATUS:
Continuing: Attended same school last year.
Transfer/Promotion: Attended another SLCUSD school.
New: Not previously enrolled in district.
Former: Returning to district after absence.
Date last attended SLCUSD _______________
PARENT/GUARDIAN INFORMATION:
A. Education level of MOST educated parent or guardian:
Graduate school/postgraduate training High school graduate
College graduate Not a high school graduate
Some college (includes AA degree) Decline to state/unknown
B. Is either parent/guardian assigned to active military duty? Yes No
SCHOOL LAST ATTENDED:
RESIDENCE: Is the student and/or family living:
1. With another family and/or relative due to Yes No
economic hardship?
2. Student not living with a parent/legal guardian? Yes No
3. In a hotel or motel? Yes No
4. At a campground, in a car, R.V., or unsheltered? Yes No
5. In a shelter? Yes No
6. In a foster home? Yes No
Address Street or P.O. Box/City/Zip and Phone
Date last attended:
Reason for leaving: Voluntary
Expulsion
Has your child ever been expelled from a school district?
Yes No If yes, when and why?
Did your child attend Preschool or Transitional Kindergarten
(TK) in SLCUSD?
Yes No If yes, which school?
STUDENT’S HEALTH PLAN / MEDICAL INSURANCE: I would like more information about the Family Resource Centers.
I would like more about free or low-cost health insurance.
None Medi-Cal/CenCal Private Insurance Plan Name: _________________________________________
Do you have vision insurance? Yes No Do you have dental insurance? Yes No
I request Spanish translation for:
school meetings district and school communications
My child has an: IEP Yes No Section 504 Plan Yes No
I GIVE PERMISSION FOR THE FOLLOWING:
Yes No I give permission for school personnel to discuss the health conditions/medications listed on my child’s Emergency
Information Card with the physician(s) listed on my child’s Emergency Information Card. I understand that permission to
contact physician is required should I ask the school to dispense medication to my child.
Yes No As a parent/guardian, I give permission for my name, address, phone number, and email address to be published in a
school directory.
Yes No As a parent/guardian, my name, address, phone number, and email address may be released for school-related use.
Yes No My child may be interviewed, have his/her picture or video taken, or appear in newspaper, on television or on radio
programs and be identified by first name.
Yes No My child’s first name, photo, and/or work samples may be posted on the Internet (including teacher, school, district
and/or district-affiliated websites) in recognition of school-related activities.
THE FOLLOWING QUESTIONS ARE FOR HIGH SCHOOL STUDENTS ONLY:
Grades 9-12 Only: Yes No I give permission to release my address to the company for class ring / diploma / cap and
gown / school pictures.
Grades 11 and 12 Only:
1. Your child’s name will be included in a directory of names and addresses provided annually to military recruiters unless you decline by opting
out here: Yes, I would like to opt my child out. I do not want their information released to military recruiters.
2. Your child’s name will be included in a directory of names and addresses provided annually to college representatives unless you decline by
opting out here: Yes, I would like to opt my child out. I do not want their information released to college representatives.
3. I approve release of my address to: Grad Night Committee Yes No Senior Portrait Package Providers Yes No
My signature indicates that the information contained herein is accurate to the best of my knowledge, that my permission is given
as indicated above and, per Section 48982 of the Education Code, that I have received, read, and understand the 2019-20 Annual
Parent Notification, which includes the Student Conduct Code and the Student Technology Responsible Use Agreement.
Parent’s/Stepparent’s/Guardian’s Signature Date AND Student’s Signature Date
Yes, I would like to be contacted regarding opting my student out of district technology use.
Student has access to internet at home: Yes No Student has access to a computer at home: Yes No
Revised 1/14/20
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SAN LUIS COASTAL UNIFIED SCHOOL DISTRICT
2021-22 STUDENT EMERGENCY INFORMATION CARD
Student’s Preferred Name
Home Phone
Birth Date (mo./day/year)
Grade
Gender (F/M/N)
Other Children in the Family:
Name Age School
1. _________________ ________ ____________________________
2. _________________ ________ ____________________________
Name Age School
3. _________________ ________ ____________________________
4. _________________ ________ ____________________________
PARENT/GUARDIAN INFORMATION (Enter names of legal parents/stepparents/guardians/caregivers only, starting with parent(s) with whom student resides.):
NOTE: Parent/Guardian contact information may be used for school-related business, such as attendance and informational messages. (Code of Federal Regulations, Title 34, 99.1-99.67 FERPA)
If you agree to allow the district to send text message reminders and announcements directly to your cell phone, please check the “Receive Texts” box below. By
checking the box, you agree to pay fees charged by your cellular service provider.
Name (First / Last)______________________________________
Address (if different from student) ______________________________________________________________________
Best phone number to call during school hours (please check one): Home Work Cell Send mailings
Student resides here: Yes No
Parent
Stepparent
Legal Guardian
Caregiver
Home Phone
Work Phone
Cell/ Receive Texts
Email
Employer
Occupation
Name (First / Last)______________________________________
Address (if different from student) ______________________________________________________________________
Best phone number to call during school hours (please check one): Home Work Cell Send mailings
Student resides here: Yes No
Parent
Stepparent
Legal Guardian
Caregiver
Home Phone
Work Phone
Cell/ Receive Texts
Email
Employer
Occupation
Name (First / Last)______________________________________
Address (if different from student) ______________________________________________________________________
Best phone number to call during school hours (please check one): Home Work Cell Send mailings
Student resides here: Yes No
Parent
Stepparent
Legal Guardian
Caregiver
Home Phone
Work Phone
Cell/ Receive Texts
Email
Employer
Occupation
Custody Order: Yes No If Yes, please attach a copy of
the order and include a schedule (i.e. Mother M-W, Father Th/F)
Restraining Order: Yes No If Yes, please attach a copy.
EMERGENCY CONTACT INFORMATION (OTHER THAN PARENT/GUARDIAN): In the absence of a legal parent, stepparent, or guardian, school staff may
notify or release my student to the person(s) listed below in case of illness, accident or evacuation. List only local persons, in the order in which they should be contacted.
First Contact: Name
Relationship
Home Phone
Work Phone
Cell
Second Contact: Name
Relationship
Home Phone
Work Phone
Cell
Third Contact: Name
Relationship
Home Phone
Work Phone
Cell
HEALTH: Physician’s Name: _______________________________________________________ Phone Number: _________________________________
The school may give first aid to any student, and the hospital/doctor may render medical treatment even though parent/guardian is not available if there is no prior
written objection to medical treatment filed with the school site. (C.E.C. 49407, 25.8)
Please list allergies and/or other health conditions that you want us to share with teachers and other school staff:
_____________________________________________________________________________________________________________________________________
Does your child wear glasses? Yes No Does your child use a wheel chair? ? Yes No
If your child has confidential health conditions that you want to share, please make an appointment with the school nurse.
MEDICATION: My student Takes continuing medication: If so, Before/After school only OR During school hours. (If medication, either prescription
or non-prescription, is to be given during school hours, a consent form signed by parent/stepparent/guardian and physician MUST be on file.)
If medication is taken during school hours, name of medication and purpose: ________________________________________________________________________
SIGNATURES
Parent’s / Stepparent’s / Guardian’s Signature: __________________________________________________________ Date: ___________________________
Parent’s / Stepparent’s / Guardian’s Signature: __________________________________________________________ Date: ___________________________
Administrative Use Only: Enroll Status: New OE AT IDT COR Alerts: Medical Custody
Entry date: _______________ Leave date: _______________
If student leaves the district, note the following information:
The student’s record was sent to (school) ___________________________________ located in (city) ___________________________ on (date) _______________
Revised on 1/14/20
Student’s Name _________________________________________
Teacher/Counselor _______________ _______________________
School _________________________ Grade ________________
Contact #1
Contact #2
Contact #3
Student’s Legal Name: ______________________________________________
FOR SECONDARY ONLY: If you agree to allow the district to call and/or send text message reminders and announcements directly to your student’s cell phone,
please enter the student cell phone number here. By entering the phone number, you agree to pay fees charged by your cellular service provider.
Student’s Cell Phone:
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W:\FORMS-District\Student Support Services\Nurse Items\Confidential Student Info for School Nurse 21-22_Eng_Fillable
Student Name: Date of Birth:
Parent Name: Phone:
Preschool TK/Kinder New Student, Grade Level:
Wears Glasses/Contacts: Yes No Reason (nearsighted, farsighted, astigmatism, etc.):
Hearing Loss/Concerns: Yes No Notes:
My Child has a Health Condition No (STOP HERE) Parent Signature: Date:
Yes, Please complete remainder of form
Asthma: Severe Mild Triggers:
Medications
*
: Taken at school Taken at home
Allergies: Anaphylaxis/Epi-pen Severe Mild Triggers:
Symptoms:
Medications
*
: ____________________________________________________________________
Date of most recent anaphylactic reaction: N/A
Diabetes: Type 1 Syringe/Pen Pump CGM Independent in care
Type 2 Medications
*
: Taken at school Taken at home
(MD school orders are required prior to school staff participation in diabetic care.)
Seizures: History Age of first incident: ______ Type: ____ Treatment:
Current Seizure Disorder Type: __ Date of most recent seizure:
Medications
*
: Taken at school Taken at home
VNS
Other Health Conditions:
Medications
*
: Taken at school Taken at home
*
The school requires a completed medication authorization form for any medication, over the counter and prescription, that is
taken at school. This applies to all student medication at school, whether it is kept in the health office or with the student. The
form must be completed annually by the parent/guardian and a licensed health care provider. Forms are available at the school
office.
Parent Signature Date Nurse Signature Date
2021
-2022 Confidential St
udent Health Information
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Revised 1/17/19
SAN LUIS COASTAL UNIFIED SCHOOL DISTRICT
Division of Educational Services
HOME LANGUAGE SURVEY
Date: School:
The California Education Code requires schools to determine the language(s) spoken at home by each student. This information is essential to
providing meaningful instruction for all students. Your cooperation in helping us meet this important requirement is requested. Please answer
the following questions and return this signed form to the school secretary.
Name of Student:
Last First Middle Grade Age
1. Which language did your son/daughter learn when he/she began to talk?
2. What language does your son/daughter most frequently use at home?
3. What language do you most frequently use when speaking to your child?
4. Name the language most often spoken by the adults at home?
Has your son/daughter taken the English Language Proficiency Assessments for California (ELPAC) in the past 12 months? No Yes
(This test is administered to prospective English Learners and annually to all English Learners.)
If yes, approximate date: __________________________
Student’s Place of Birth: City _____________________________________ State ____________________
Country: USA Other: ________________________________
Date First Enrolled in a U.S. School ________________________
ETHNICITY
Part I: Mark one.
Hispanic or Latino
Not Hispanic or Latino
ETHNICITY/RACE
Part II: In addition to your response in Part I, mark one or more boxes below.
Asian
Asian Indian American Indian or Alaskan Native
Cambodian Black or African American
Chinese White
Filipino
Hmong Native Hawaiian or Other Pacific Islander
Japanese Guamanian
Korean Hawaiian
Laotian Samoan
Vietnamese Tahitian
Other Asian Other Pacific Islander
Other Asian Other Pacific Islander
The information contained herein is accurate to the best of my knowledge. _________________________________________
Signature of Parent/Stepparent/Guardian
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2021-22 STUDENT INFORMATION CARD (San Luis Coastal Unified School District)

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Completed 28 May 2021

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