Fillable LOS ANGELES UNIFIED SCHOOL DISTRICT Early Childhood Education (Los Angeles Unified School District)

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LOS ANGELES UNIFIED SCHOOL DISTRICT Early Childhood Education (Los Angeles Unified School District)

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ADD FIELDS

This document should be included in the family file.

Child Name/s:

____________________________________________ Date of Birth: ____________________

Welcome to our Early Education Center. In order to enroll your child, please have available and completed by

your appointment date, the documents & information checked below:

(

LAUSD SECTION)

Received

COMPLETE

Scanned

to EESIS

◊

Birth Certificate or Baptismal Record of ALL children under 18 years of age in the family.

 

◊

Immunization records for child being enrolled (California Immunization Requirements for

Child Care

01/19

)

 

◊

Proof of income – One full month’s worth of check stubs for the prior month for each parent

employed. (If paid weekly, submit the last 4 consecutive check stubs, if paid bi-weekly,

submit the last 2 consecutive check stubs.)

 

◊

Verification of TANF or other cash assistance (copy of most recent check – prior month,

Notice of Action or Cash Issuance Receipt)

 

◊

Verification of California Residency (CA ID, CA Driver’s License, Current Utility Bill, Rent

Receipt, Lease Agreement, etc.)

 

ATTACHMENTS

◊

Home Language Survey

Student Enrolment Form Ref 5259.1 08/19

 

◊

Health History Card (white, to be completed by the parent/guardian)

07/86



◊

Physical Exam – Physician’s Report (LIC 701 form to be completed by the doctor. Must

be within the last 12 months and include screening of TB risk)

08/08



◊

Verification of Employment and Salary – Form 83.56

04/19

 

◊

Self-Certification of Income (if applicable)

04/19

 

◊

Verification of Training – Form EESD 9605

01/15

(Progress Report at Recertification Time)

 Request for study time must be written and provided by parent

 

◊

Statement of Incapacity – CD 9606

06/08

 

◊

Child Protective Services Referral Form 83.66

06/19

 

◊

Seeking Employment Agreement

04/18

 

◊

Los Angeles Unified School District Parent Handbook – Forms completed & signed

SY 20-21



◊

Student Emergency Information Form (At least 3 names, addresses and telephone

numbers of persons, 18 years or older, authorized to pick up your child in case of

emergency or illness) Make sure that the name matches what appears on Driver License

or I.D.s

01/14

 

◊

If Applicable: Verification of Other Care Providers – Form 84.26

03/19

 

◊

Student Housing Questionnaire

07/19

; Migrant Education Program Questionnaire

10/18

& Safe

Gun Storage Acknowledgement Form

09/19



◊

Other : _________________________________________________________________



Your appointment date is _______________________________________ Time: _________ AM / PM

You must bring all requested documents on that date, and be ready to stay 30 minutes, so that we can verify

the information and give you the policies and procedures of this program. If you do not show up to your

appointment, we will proceed to enroll the next family on our waiting list.

This document should be included in the family file.

PARENT ENROLLMENT PACKET CHECKLIST

LOS ANGELES UNIFIED SCHOOL DISTRICT

Early Childhood Education

EEC ______________________________________

Phone: _____________ E-mail: _________________

This document sho

uld be included in the family file.

____________________________________

This document should be included in the family file.

FOR LAUSD USE ONLY

CASE NOTES

FOR LAUSD USE ONLY

EESIS ID# _____________ Parent/s Name________________________ Room # ________

Child Name ________________________ Birthda

y ____________ Program  CCTR  CSPP

Has the family previously been enrolled in a LAUSD ECED Program?  YES  NO

CONTRACT SIGNATURES

COMPLETE

SCANNED

TO EESIS

 Notice of Action (CD 7617) – with Parent initial or receipt of certified mail and Principal

signature

 

 CD 9600 page 1 & 2 – with proper box checked, dated, initialed (Single Parent) and Signed

by Parent and Principal

 

LOS ANGELES UNIFIED SCHOOL DISTRICT

Early Childhood Education

EEC ______________________________________

Phone: _____________ E-mail: _________________

LOS ANGELES UNIFIED SCHOOL DISTRICT

REFERENCE GUIDE

Attachment A

REF-5259.1

Student Health and Human Services

August 16, 2019

STUDENT ENROLLMENT FORM

Student Name: Date of Birth (Month/Day/Year): / /

C. HOMELANGUAGEANDETHNICITYINFORMATION

HomeLanguageoftheStudent

Whichlanguagedidyourchildlearnwhenhe/she/theyfirstbegan

totalk?

Whichlanguagedoesyourchildmostfrequentlyuseathome?

Whichlanguagedoyou(theparentsorguardians)mostfrequently

usewhenspeakingtoyourchild?

Whichlanguageismostoftenspokenbyadultsinthehome?

(parents,guardians,grandparents,oranyotheradults)

HasthisstudentreceivedanyformalEnglishlanguageinstruction? ☐ Yes ☐ No

Student’sPrimaryEthnicity

Isthestudent’sethnicityHispanicorLatino? ☐ Yes ☐ No

Student’sPrimaryRace(CheckOne)

☐ AfricanAmericanor

Black

☐ AmericanIndianorAlaskaNative ☐ White

Asian:

☐ AsianIndian ☐ Cambodian ☐ Chinese ☐ Filipino ☐ Hmong

☐ Vietnamese ☐ OtherAsian:

☐ Japanese ☐ Korean ☐ Laotian

PacificIslander:

☐ Guamanian ☐ NativeHawaiian ☐ Samoan ☐ Tahitian

☐ OtherPacificIslander:

☐ DeclinetoState

Student’sAdditionalRace(Optional)

☐ AfricanAmericanor

Black

☐ AmericanIndianorAlaskaNative ☐ White

Asian:

☐ AsianIndian ☐ Cambodian ☐ Chinese ☐ Filipino ☐ Hmong

☐ Vietnamese ☐ OtherAsian:

☐ Japanese ☐ Korean ☐ Laotian

PacificIslander:

☐ Guamanian ☐ NativeHawaiian ☐ Samoan ☐ Tahitian

☐ OtherPacificIslander:

☐ DeclinetoState

SIGNATURE

I verify that the information contained in this document is true and correct to the best of my knowledge.

Signature Date

Printed Name Relationship to Student

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LOS$ANGELES$UNIFIED$SCHOOL$DISTRICT$–$PERMANENT(HEALTH(HISTORY(

Students$Name$$$_______________________________________$$Sex:$$M$___$F___$Birth$Date$_________________$

LAST$$$$$$$$$$$$$$$FIRST$ $ MIDDLE$$$$$$$$$$$$$$ $ $ $ $$$$$$$$$$$$$$MONTH$$$DAY$$$$YEAR$

Last$School$or$Children’s$Center$Attended:_______________________________

Name$$$$$$$$

Location$$__________________________________________________________$

City$&$State$

Present$Grade$________$

SPECIAL$CLASS$OR$SCHOOL$$___________________________________________$

Health$Care$Provider/Physician$______________________________$

Date$of$late$physical$examination$____________________________$

Family$Dentist$____________________________________________$

Date$of$last$dental$examination$______________________________$

CHILD’S$ILLNESS$(past$or$present)$please$check$(√):$

FAMILY:$

Father$

Living$with$child(Names)$

HEALTH$

Chickenpox$

Yes

Frequent$sore$throat$

Yes

Mother

Meningitis

Ear$aches/infections

Stepparent

Mumps

Hearing$loss

Others

Rubella$(3$day$measles)

Speech$problem

Brothers$

How$Many$Older$

How$Many$Younger$

HEALTH$

Rubeola$(10-day$measles)

Eye$problem

Whooping$Cough

Wears$glasses/contacts

Sisters

Positive$TB$Skin$Test

Heart$condition/murmur

Has$child$ever$been$hospitalized$overnight?$$$Yes$___$$$No$___$

Name$of$hospital$_____________________City______________State_________$

Dates in hospital ____________________________________________________$

Reasons$for$hospitalization$___________________________________________$

__________________________________________________________________$

Is$child$on$medicatio n ? $$Y es $_ _ __ $$$N o $_ _ _ _$

Name of medicine __________________________________________________$

Amount$$$_____________________$$Frequency$___________________________$

Are physical activities limited?$ Yes ______$ No______$

If$yes,$reason$for$limita tio n :$__ _ _ _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ _$

Bronchitis

High$Blood$Pressure

Pneumonia

Kidney$Problem

Asthma

Diabetes

Hives$or$Eczema

Blood$disease

Drug$or$Other$Allergy

Menstrual$problem

Head$Injury

Hernia

Seizures/Unconscious

Parasites(worms)

Other$serious$accidents$or$illness$(describe)$______________________$

BIRTH(HISTORY(

MOTHER’S$PREGNANCY:$$

$$$$$$$$Infections$

YES(

NO(

DEVELOPMENT(HISTORY(

At$what$age$did$your$child:$

Sit$alone$_________________$$ $$Crawl$_________________________$

Stand$alone$______________$$ $$$$Walk$_________________________$

Say$words$________________$$ $$Use$sentences$_________________$

Toilet$train$_______________$$ $$Feed$self$______________________$

$$$$$$$$Bleeding$

$$$$$$$$High$Blood$Pressure$

$$$$$$$$Toxemia$

$$$$$$$Diabetes$

$$$$$$$$Other$Complications$of$Pregnancy$

PLEASE$CHECK$($$)$DOES$YOUR$CHILD:$

9-Month$Pregnancy

Enjoy$learning$

YES

Bite$nails$

YES

$$$$$$$$Type$of$Delivery$

Like$school

Suck$thumb

Child’s$birth$weight__________$

child’s$birth$condition$(check)$$$$$$$$$good$_______$$$$poor$________$

If$poor,$describe:$___ _ _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ __$

__________________________________________________________________$$

Like$other$children

Wet$bed

Eat$well

Seem$shy

Drink$milk

Fall$frequently

Eat$Breakfast

Have$temper$tantrums

Sleep$well

Seem$overactive

Follow$directions

ILLNESS$DURIN G $F IRS T $2 $WEEKS$OF$LIFE:$$$$$

$$$$$$Trouble$breathing$

YES(

NO(

What$time$does$your$child$go$to$bed?$___________________________$

Do$you$have$any$questions$or$concerns$about$your$child’s$health?$

Please$list. _________________________________________________$

$$$$$$Seizures$

Cyanosis(blue$color)

Jaundice(yellow$color)$

Feeding$problems

_______$$$$$$$$_______________________________________________$

$$Date$$ $$Parent/Guardian$Signature$

_______$$ $$_______________________________________________$

$$Date$$ $$History$taken$by$(Name)$

$_______________________________________________$

Title$

_______________________________________________$

Name$of$School$

Anemia

$$$$$$$Birth$defect$

Required$incubator

$$$$$$$Went$home$with$mother$

FORM(34-EH-67(7/86(

STK.(NO.(815292((((((((

((LOS$ANGELES$UNFIED$SCHOOL$DISTRICT$

C.C.9661215292

((Stu dent$ Health$and Human Services$Division$

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VERIFICATIONOFEMPLOYMENT



PARENTSECTION:

Californiastatelaw(5CCR18084)requiresthatfamiliesreceivingLAUSDearlychildhoodeducationservicesdocument

total income.I agree to provide check stubs or other record of wages.I authorize my employer to release the

followinginformationtotheearlychildhoodeducationprogramnamedabove.Ialsoauthorizetheearlychildhood

educationprogramtocontactmyemp

loyertoverifyanyinformationindicatedonthisform.

_____________________________ ____________________________ _________________

Parent/EmployeeName SignatureofParent/Employee Date

EMPLOYERSECTION:



Pleasecompleteandreturntothelocationshownabove.



Employer:_______________________________________________Phone: _____________________

Address:______________ __________________________________

BusinessHours:______________

EmployeePosition/Department:____

________________________DateofHire:________________

Howistheem

ployeepaid?



Weekly

Bi‐

Weekly

Bi‐Monthly





Every4Weeks



Monthly

Paidby:





Cash



Check 

GROSSEarningsPerPayPeriod:_____________



Possibilityof?

NumberofHoursEmployedPerWeek____________

HourlyRate$________ ___



Tips



Overtime



DAYSANDHOURSOFEMPLOYMENT

HOURS MONDAY TUESDAY WEDNES DAY THURSDAY FRIDAY SATURDAY SUNDAY

FROM:

TO:

Ifworkingavariableschedule,pleasecheckone:



Daysvary



Hoursvary



Daysandhoursvary

Pleaseexplain:________________________________________________________ ____________________ 

_____________________________ _______________________________ ________________

EmployerName/Title  SignatureofEmployerRepresentative Date

LAUSDSECTION:

Traveltimerequested



30minutes



60minutes



Student’sName:______________________________________________FamilyID:___________________

Meansofverification:_____________________________________________________________________

Notes:__________________________________________________________________________________

VerifiedBy:______________________________________Date:______________________________

Form83.56Rev.4/2019

LOSANGELESUNIFIEDSCHOOLDISTRICT

EarlyChildhoodEducation

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PARENTSECTION:

Nameofparent: ____ FamilyID:_____________________

Child:_________________________

1. Self‐certificationofemploymentincomeisrequestedforthefollowingreason:

 TheearlyeducationprogramrequestedthatIcompletethisformbecausemyemployerhas

refusedorfailedtoprovidemyemploymentinformation.

 I have asked that my employer not be contacted to verify my employment because that

contactcouldputmyemploymentatrisk.

 Idonothavepaystubs,receiptsorotherdocumentationofemployment.

 Other

EMPLOYER

Datehired:

Typeofworkperformed:

Rateofpay:

($___per____)

$

Howoftenpaid?

(Weekly,monthly,etc.)

Paidby:

(Cash,check)

Workdayhours:

(___AM‐___PM)

Daysworkedeachweek:

(Mon.‐Fri.)

Totalpaidforthemonth:

$



2. Self‐certificationofnon‐employmentincomewhennodocumentationispossible:



Whattype?

Howmuch?

Howoften?

Why?

Ideclare under penalty of perjury thatthe above information is trueand correct to the best of my

knowledge.IunderstandthatImaybeaskedtodocumentmyactivitieseachweek.

_________________________________________ _____________________

ParentSignature Date

LAUSDSECTION:

Notes:__________________________________________________________________________

AssessedBy:_____________________________________Date:_______________________

Rev.4/2019

LOSANGELESUNIFIEDSCHOOLDISTRICT

EARLYCHILDHOODEDUCATION

SELF‐CERTIFICATIONOFINCOME

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Training Verification –Parent or Caretaker Attending School or Receiving Training

Date

Agency Name, Street Address, City, ZIP Code, and

Phone Number

Parent Name, Street Address, City, ZIP Code, and Phone

Number

Signature_______________________________________

Training/Education Information

Profession/Vocational Goal (Not Academic Goal) (E.g. Vocational Goal is to become a teacher.) (E.g. Academic

Goal is to obtain Degree or Certificate)

Name of School or Organization where

training/education is received

Phone Number

Street Address, City, Zip Code

Anticipated Completion Date for Training/Education

Date this Term Began Date this Term Ends

Complete One of the Following

Attached is the parent’s course printout form from the training institute.

Below is the parent’s class schedule with the signature and stamp of the Registrar’s office.

Class Schedule (if applicable)

Day Time Room # Course Name Units

Signature and Stamp of Registrar of School/Organization

Date of Signature and Seal

California Department of Education

Early Education and Support Division

Form EESD-9605

(

Januar

2015

)

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CALIFORNIA DEPARTMENT OF EDUCATION NOTE: When applicable, this form is to be completed

Early Education and Support Division and used with form, CD-9600.

Form CD-9606, (Rev. June 2008)

STATEMENT OF PARENTAL INCAPACITY Please print or type information.

PART I – To be completed by the authorized agency representative and the incapacitated parent.

By signing this form and for the purpose of verifying my incapacity to care for the family’s children as it relates to the family’s eligibility for

subsidized child care and development services, I authorize and request the health professional named in Part II to release the information

requested to the agency identified below. I further authorize the health professional to discuss this Statement of Incapacity with the agency

in order for the agency to verify, clarify, or complete it. I understand the health professional may also require that I complete his or her own

release form prior to providing the information requested below.

NAME OF PARENT/CARETAKER SIGNATURE OF PARENT/CARETAKER DATE

FIRST NAME AND AGE OF THE CHILD(REN) FOR WHOM FINANCIAL ASSISTANCE FOR CHILD CARE IS BEING REQUESTED:

1. 2. 3. 4.

AGENCY AUTHORIZED AGENCY REPRESENTATIVE (Please print.) TELEPHONE NUMBER

( )

ADDRESS CITY ZIP CODE

PART II – To be completed by the licensed health professional.

For the family to be eligible to receive child care and development services under the category of incapacity, the California law requires

verification, at least annually, of the physical or mental incapacity of the parent or caretaker that renders the person incapable of caring for or

supervising the family’s child(ren) without assistance. (See California Code of Regulations, Title 5, §18088.) Your cooperation in completing

and returning this form to the agency listed above within 15 days of receipt is requested.

PATIENT ___________________ HAS

a physical condition or

a mental health condition

that prevents him or her from providing

care or supervision for the child(ren)

listed above for at least part of the day.

Please indicate the time in a day and the days of the week, not to exceed 50 hours in a week,

that the parent is unable to care for or supervise the child(ren).

Child

care

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Start

Time:

am/

End

Time:

am/

PROBABLY DATES OF INCAPACITY

From: To:

If the time of day cannot be easily identified in consultation with the patient, please identify the number of

hours and days of the week [M, T, W, T, F, S, S] that services are needed.

If the parent has a physical/medical condition, please identify the extent to which the parent is incapable of providing care and

supervision.

Please sign and submit this form to the agency listed in Part I within 15 days of receipt of this for

NAME OF LICENSED HEALTH PROFESSIONAL

LICENSE TYPE LICENSE NUMBER

SIGNATURE OF LICENSED HEALTH PROFESSIONAL

DATE TELEPHONE NUMBER

( )

MEDICAL GROUP OR ORGANIZATION WITH WHICH THE PROFESSIONAL IS AFFILIATED, IF ANY

ADDRESS CITY STATE ZIP CODE

CenterName:_ ________________________

___________________

Email: ________________________

Address:, _______________________________Phone:

(___)-__________Fax:(___)-_____________

CHILDSECTION

Child(ren)beingreferredforEarlyChildhoodEducatio nServices:

ChildName

:_____________________________________

ChildName

:__________________________________

Birthdate:________________   Birthdate:________________

Livingwith:Parent/GuardianName:________________

_______________________

Isthechildinanout‐of‐homepla cement?YesNo Ifyes,childislivingwith:

 Relative‐relationship:________________

____FosterParent Other(describe)_________________

Probabledurationofservices*:______________ ____________Hourscareneeded:_____________________

*Nottoexceed12monthsforchildprotectiveservicesorchildatriskofabuse,neglectorexploitation

DCFSREFERRALSECTION



ForusebyLosAngelesCountyDepartmentofChildrenandFamilyServicesonly

 I certify that the child(ren) is receiving child protective services and child care and development services are a necessary

componentofthechildprotectiveservicesplan.

 Ialsocertify thatitisnecessary to waive any family feeandincomeinformation will not be required from thefamily. Fee

exemptions cannot be granted beyond 12 months regardless of whether the child continues to receive child protective

services.The12monthtimelimitisacumulativetotal.

 If Early Childhood Education services have continued for 12 months, I certify that the family continues to receive child

protectiveservicesandthatchildcareanddevelopmentservicesarepartofthecaseplan.

DCFSCaseNumber:______________________________

________________________________________________________________ _______________

DCFSRepresentativeName/Title Signature Date

Address:______________ ________________Phone:_________________Email:__

_________________________

ATRISKREFERRALSECTIONForusebyallorganizations/entitiesotherthanDCFS

 IcertifythatIamalegallyqualifiedprofessionalfromaleg

al,medical,socialserviceagency,oremergencyshelterandthat

childcareservicesarerequiredtoreduceoreliminatetheriskofabuse,neglectorexploitationofthechild(ren).Iunderstand

thattheseservicesarelimitedto12months.



Ialsocertifythatitisitisnecessarytowaiveanyfamilyfeeforthe12monthsandincomeinformationwillnotberequired

fromthefamily.

ReferringAgency:______________ ___________________ CaseNumber:__________________

____________________________________ __________ _____________________ ________________

ReferringProfessionalName/Title Signature Date

Address:______________ ________________ Phone:______________

Email:___________________________

Form83.66(Rev.06/19)

LOSANGELESUNIFIEDSCHOOLDISTRICT

EARLYCHILDHOODEDUCATIONDIVISION

CHILD PROTECTIVE SERVICES / AT RISK REFERRAL



LAUSDSECTION:

Nameofparent:FamilyID:____________



Effectivedateofseekingemployment:



Californiastatelaw(5CCR18086.5)requiresthateligibilityforseekingemploymentislimitedto12

months.



Youwillusethemaximumnumberofdaysallowableon_______________________.Ifbythatdate

youhavenotsecuredemployment,childdevelopmentservicestoyourfamilymaybeterminated.



PARENTSECTION:



1. Please indicatetheactivitiesyouwillusetoactivelyseekemployment:





Lookforjobsinthenewspaper



Makephonecalls



Usetheinternet



Writeandsendresumes



Applyforin‐personinterviews



Applytoanemploymentagency



Visitcollegeplacementcenter



Godoor‐to‐door



GototheEmploymentDevelopmentDepartment(UnemploymentOffice)



Other



2. Pleaseindicateifyouwouldlike:





Asetschedule(samehourseachday,nottoexceed30hourseachweek)



Avariableschedule(variedhoursbaseduponseekingemploymentactivities,notto

exceed30hourseachweek)



Ifyouwouldlikeafixedschedule,indicatethehoursanddaysoftheweekyouwilluseto

activelyseekemployment:



HOURS MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

FROM:



TO:





IdeclareunderpenaltyofperjurythatIamseekingemploymentandthattheabove

informationistrueandcorrecttothebestofmyknowledge.IunderstandthatImay

beaskedtodocumentmyactivitieseachweek.Iwillnotifythecenterimmediately

ifthereisanychangeinmyemploymentstatus.



_______________________________________________ _____________________

ParentSignatureDate



BUL‐4363.0Rev.04/2018

LOSANGELESUNIFIEDSCHOOLDISTRICT

EARLYCHILDHOODEDUCATION



SEEKINGEMPLOYMENTAGREEMENT

Los Angeles Unified School District

Parent/Guardian Publicity Authorization and Release

Dear Parent/Guardian:

The Los Angeles Unified School District requests your permission to reproduce through printed, audio, visual, or electronic means

activities in which your pupil has participated in his/her education program. Your authorization will enable us to use specially

prepared materials to (1) train teachers and/or (2) increase public awareness and promote continuation and improvement of

education programs through the use of mass media, displays, brochures, websites, etc.

1. Name of Pupil (please print) 2. Birthdate (please print)

3. Name of Parent (please print)

a. I, as a parent of guardian, of the above named pupil fully authorize and grant the Los Angeles Unified School District and its

authorized representatives, the right to print, photograph, record, and edit as desired, the biographical information, name,

image, likeness, and/or voice of the above named pupil on audio, video, film, slide, or any other electronic and printed formats,

currently developed, (known as “Recordings”), for the purposes stated or related to the above.

b. I understand and agree that use of such Recordings will be without any compensation to the pupil or the pupil’s parent or

guardian.

c. I understand and agree that the Los Angeles Unified School District and/or its authorized representatives shall have the

exclusive right, title, and interest, including copyright, in the Recordings.

d. I understand and agree that the Los Angeles Unified School District and/or its authorized representatives shall have the

unlimited right to use the Recordings for any purposes stated or related to the above.

e. I hereby release and hold harmless the Los Angeles Unified School District and its authorized representatives from any and all

actions, claims, damages, costs, or expenses, including attorney’s fees, brought by the pupil and/or parent or guardian which

relate to or arise out of any use of these Recordings as specified above.

__________________________________________________________________________________________________________

My signature shows that I have read and understand the release and I agree to accept its provisions.

4. Signature of Parent/Guardian 5. Date Signed

6. Address (Number, Street, Apartment Number)

7. City 8. State 9. Zip Code

10. Telephone

Granting of permission is voluntary. Please return completed form to school.

11. Principal Approved as to form by the

Office of the General Counsel.

This form shall not be amended without

12. School written approval of both the Office of the

General Counsel and the Office of

Communications/Public Information

LOS ANGELES UNIFIED SCHOOL DISTRICT

STUDENT EMERGENCY INFORM ATION FORM

Parent Information: Please fill out completely and sign where indicated. In a major emergency, it is school district policy to retain students at school for their safety.

This form will be used by the school staff when students are released to go home. Please complete electronically or print clearly and return completed form to school.

STUDENT’S LAST NAME

FIRST NAME

M.I.

STUDENT’S LAST NAME

BIRTH DATE

GRADE

HOME LANGUAGE

MALE FEMALE

STUDENT’S HOME ADDRESS -- NUMBER

STREET

APT #

CITY

ZIP CODE

MAILING ADDRESS -- NUMBER

(IF DIFFERENT FROM ABOVE)

STREET

APT #

CITY

ZIP CODE

PARENT’S / LEGAL GUARDIAN’S LAST NAME

FIRST NAME

RELATIONSHIP TO STUDENT

LIVES WITH?

Yes No

WORK ADDRESS -- NUMBER

STREET

CITY

ZIP CODE

CONTACT NUMBERS

Indicate which phone to call for each message type:*

EMAIL ADDRESS:

HOME

EMERGENCY

Home

Cell

Work

CELL

ATTENDANCE

Home

Cell

Work

WORK

GENERAL INFO

Home

Cell

Work

TEXT

I authorize receiving text messages and understand that I am responsible for all text related charges.

PARENT’S / LEGAL GUARDIAN’S LAST NAME

FIRST NAME

RELATIONSHIP TO STUDENT

LIVES WITH?

Yes No

WORK ADDRESS -- NUMBER

STREET

CITY

ZIP CODE

CONTACT NUMBERS

Indicate which phone to call for each message type:*

EMAIL ADDRESS:

HOME

EMERGENCY

Home

Cell

Work

CELL

ATTENDANCE

Home

Cell

Work

WORK

GENERAL INFO

Home

Cell

Work

TEXT

I authorize receiving text messages and understand that I am responsible for all text related charges.

To the principal: In case you are unable to reach me during any emergency, you are authorized to contact and, if necessary, release my child to any of the following:

NAME

RELATIONSHIP

HOME PHONE

CELL PHONE

WORK PHONE

FIRST NAME

NAME

RELATIONSHIP

HOME PHONE

CELL PHONE

WORK PHONE

NAME

RELATIONSHIP

HOME PHONE

CELL PHONE

WORK PHONE

List any other family members attending this school:

LAST NAME

FIRST NAME

HOME ROOM

GRADE

RELATIONSHIP

LAST NAME

FIRST NAME

HOME ROOM

GRADE

RELATIONSHIP

MILITARY CONNECTED FAMILY: In efforts to provide

resources and support to military connected students and their

families, please respond to the following:

Immediate family member in the military (Active Duty,

Guard, Reserve, or Veteran): YES NO

Relationship to Student: ______________________

Currently Deployed: YES NO

Military Branch: ____________________________________________

Status: Active Duty; Guard; Reserve; Veteran; Deceased

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT

The undersigned, as parent/legal guardian of,

a minor,

(Print name of the student here)

hereby authorizes the principal or designee, into whose care the student has been entrusted, to consent to any X-ray examination, anesthetic, medical or surgical diagnosis, treatment, and/or hospital care

to be rendered to the student upon the advice of any licensed physician and/or dentist. It is understood that this authorization is given in advance of any required diagnosis, treatment, or hospital care and

provides authority and power to the Los Angeles Unified School District (“District”) to give specific consent to any and all such diagnosis, treatment, or hospital care which a licensed physician or dentist

may deem necessary. This authorization is given in accordance with Section 49407 of the California Education Code, and shall remain effective until revoked in writing and delivered to the District. I

understand that the District, its officers and its employees assume no liability of any nature in relation to the transportation of the student. I further understand that all costs of paramedic transportation,

hospitalization, and any examination, X-ray, or treatment provided in relation to this authorization shall be my sole responsibility as the student’s parent/guardian.

HEALTH ALERTS -- List any medical condition which restricts physical activity or requires special attention. Include conditions such as asthma and allergies such as

peanut and bee stings. If none, please indicate “none”.

DOES THE STUDENT HAVE HEALTH INSURANCE? (Check One) YES NO* If “Yes”: Private Health Insurance Medi-Cal Healthy Families

MEDI-CAL / HEALTHY FAMILIES ID Number:

MIDDLE INITIAL

1. PRIVATE HEALTH INSURANCE NAME

GROUP NO.

2. PRIVATE HEALTH INSURANCE NAME

(If covered under more than one plan)

GROUP NO.

NAME OF DOCTOR / MEDICAL OFFICE

PHONE NUMBER OF DOCTOR / MEDICAL OFFICE

*If the student currently does not have health insurance, information on free or low-cost health care programs is available by calling the District’s toll-free HELPLINE 1(866)742-2273.

MY CHILD IS ALLERGIC TO THE FOLLOWING MEDICATIONS:

MY CHILD CURRENTLY TAKES THE FOLLOWING MEDICATIONS:

I CERTIFY THAT I HAVE READ AND UNDERSTOOD THIS FORM AND DO HEREBY GIVE MY AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT, AND THAT ALL OF THE INFORMATION I

HAVE PROVIDED ON THIS FORM IS TRUE AND CORRECT.

DATE

SIGNATURE OF: (CHECK ONE) PARENT LEGAL GUARDIAN CAREGIVER (AFFIDAVIT)

Selected telephone number must be a direct dial number (no extensions). Revised January 2014

STUDENT EMERGENCY INFORMATION FORM

To the principal: In case you are unable to reach me during any emergency, you authorized to

contact and, if necessary, release my child to any of the following:

# Name Relationship Home Phone Cell Phone Work Phone

I CERTIFY THAT I HAVE READ AND UNDERSTOOD THIS FORM AND DO HERREBY GIVE MY

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT, AND THAT ALL OF THE

INFORMATION I HAVE PROVIDED ON THIS FORM IS TRUE AND CORRECT.

SIGNATURE OF PARENT/LEGAL GUARDIAN DATE

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LOS ANGELES UNIFIED SCHOOL DISTRICT Early Childhood Education (Los Angeles Unified School District)

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Completed 8 March 2022

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