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. HOMELANGUAGEANDETHNICITYINFORMATION
HomeLanguageoftheStudent
Whichlanguagedidyourchildlearnwhenhe/she/theyfirstbegan
totalk?
Whichlanguagedoesyourchildmostfrequentlyuseathome?
Whichlanguagedoyou(theparentsorguardians)mostfrequently
usewhenspeakingtoyourchild?
Whichlanguageismostoftenspokenbyadultsinthehome?
(parents,guardians,grandparents,oranyotheradults)
HasthisstudentreceivedanyformalEnglishlanguageinstruction? Yes No
Student’sPrimaryEthnicity
Isthestudent’sethnicityHispanicorLatino? Yes No
Student’sPrimaryRace(CheckOne)
AfricanAmericanor
Black
AmericanIndianorAlaskaNative White
Asian:
AsianIndian Cambodian Chinese Filipino Hmong
Vietnamese OtherAsian:
Japanese Korean Laotian
PacificIslander:
Guamanian NativeHawaiian Samoan Tahitian
OtherPacificIslander:
DeclinetoState
Student’sAdditionalRace(Optional)
AfricanAmericanor
Black
AmericanIndianorAlaskaNative White
Asian:
AsianIndian Cambodian Chinese Filipino Hmong
Vietnamese OtherAsian:
Japanese Korean Laotian
PacificIslander:
Guamanian NativeHawaiian Samoan Tahitian
OtherPacificIslander:
DeclinetoState
SIGNATURE
I verify that the information contained in this document is true and correct to the best of my knowledge.
X
Signature Date
Printed Name Relationship to Student
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signature
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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$$___________________________________________$
FAMILY:$
Father$
Living$with$child(Names)$
HEALTH$
Chickenpox$
Yes
NO
Frequent$sore$throat$
Yes
NO
Mother
Meningitis
Ear$aches/infections
Stepparent
Mumps
Hearing$loss
Others
Rubella$(3$day$measles)
Speech$problem
Brothers$
How$Many$Older$
How$Many$Younger$
HEALTH$
Rubeola$(10-day$measles)
Eye$problem
Whooping$Cough
Wears$glasses/contacts
Sisters
Positive$TB$Skin$Test
Heart$condition/murmur
Has$child$ever$been$hospitalized$overnight?$$$Yes$___$$$No$___$
Name$of$hospital$_____________________City______________State_________$
Dates in hospital ____________________________________________________$
Reasons$for$hospitalization$___________________________________________$
__________________________________________________________________$
Is$child$on$medicatio n ? $$Y es $_ _ __ $$$N o $_ _ _ _$
Name of medicine __________________________________________________$
Amount$$$_____________________$$Frequency$___________________________$
Are physical activities limited?$ Yes ______$ No______$
If$yes,$reason$for$limita tio n :$__ _ _ _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ _$
Bronchitis
High$Blood$Pressure
Pneumonia
Kidney$Problem
Asthma
Diabetes
Hives$or$Eczema
Blood$disease
Drug$or$Other$Allergy
Menstrual$problem
Head$Injury
Hernia
Seizures/Unconscious
Parasites(worms)
BIRTH(HISTORY(
MOTHER’S$PREGNANCY:$$
$$$$$$$$Infections$
YES(
NO(
$$$$$$$$Bleeding$
$$$$$$$$High$Blood$Pressure$
$$$$$$$$Toxemia$
$$$$$$$Diabetes$
$$$$$$$$Other$Complications$of$Pregnancy$
9-Month$Pregnancy
Enjoy$learning$
YES
NO
Bite$nails$
YES
NO
$$$$$$$$Type$of$Delivery$
Like$school
Suck$thumb
Child’s$birth$weight__________$
child’s$birth$condition$(check)$$$$$$$$$good$_______$$$$poor$________$
If$poor,$describe:$___ _ _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ __$
__________________________________________________________________$$
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:$$$$$
$$$$$$Trouble$breathing$
YES(
NO(
$$$$$$Seizures$
Cyanosis(blue$color)
Jaundice(yellow$color)$
Feeding$problems
_______$$$$$$$$_______________________________________________$
$$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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signature
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signature
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signature
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VERIFICATIONOFEMPLOYMENT
PARENTSECTION:
Californiastatelaw(5CCR18084)requiresthatfamiliesreceivingLAUSDearlychildhoodeducationservicesdocument
total income.I agree to provide check stubs or other record of wages.I authorize my employer to release the
followinginformationtotheearlychildhoodeducationprogramnamedabove.Ialsoauthorizetheearlychildhood
educationprogramtocontactmyemp
loyertoverifyanyinformationindicatedonthisform.
_____________________________ ____________________________ _________________
Parent/EmployeeName SignatureofParent/Employee Date
EMPLOYERSECTION:

Pleasecompleteandreturntothelocationshownabove.

Employer:_______________________________________________Phone: _____________________
Address:______________ __________________________________
BusinessHours:______________
EmployeePosition/Department:____
________________________DateofHire:________________
Howistheem
ployeepaid?

Weekly
Bi
Weekly
BiMonthly


Every4Weeks

Monthly
Paidby:

Cash
Check 
GROSSEarningsPerPayPeriod:_____________

Possibilityof?
NumberofHoursEmployedPerWeek____________
HourlyRate$________ ___
Tips
Overtime
DAYSANDHOURSOFEMPLOYMENT
HOURS MONDAY TUESDAYWEDNES DAY THURSDAY FRIDAY SATURDAY SUNDAY
FROM:
TO:
Ifworkingavariableschedule,pleasecheckone:
Daysvary
Hoursvary
Daysandhoursvary
Pleaseexplain:________________________________________________________ ____________________
_____________________________ _______________________________ ________________
EmployerName/Title SignatureofEmployerRepresentative Date
LAUSDSECTION:
Traveltimerequested
30minutes
60minutes
Student’sName:______________________________________________FamilyID:___________________
Meansofverification:_____________________________________________________________________
Notes:__________________________________________________________________________________
VerifiedBy:______________________________________Date:______________________________
Form83.56Rev.4/2019
LOSANGELESUNIFIEDSCHOOLDISTRICT
EarlyChildhoodEducation
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signature
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signature
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PARENTSECTION:
Nameofparent: ____ FamilyID:_____________________
Child:_________________________
1. Selfcertificationofemploymentincomeisrequestedforthefollowingreason:
TheearlyeducationprogramrequestedthatIcompletethisformbecausemyemployerhas
refusedorfailedtoprovidemyemploymentinformation.
I have asked that my employer not be contacted to verify my employment because that
contactcouldputmyemploymentatrisk.
Idonothavepaystubs,receiptsorotherdocumentationofemployment.
Other
EMPLOYER
Datehired:
Typeofworkperformed:
Rateofpay:
($___per____)
$
Howoftenpaid?
(Weekly,monthly,etc.)
Paidby:
(Cash,check)
Workdayhours:
(___AM‐___PM)
Daysworkedeachweek:
(Mon.‐Fri.)
Totalpaidforthemonth:
$
2. Selfcertificationofnonemploymentincomewhennodocumentationispossible:
Whattype?
Howmuch?
Howoften?
Why?
Ideclare under penalty of perjury thatthe above information is trueand correct to the best of my
knowledge.IunderstandthatImaybeaskedtodocumentmyactivitieseachweek.
_________________________________________ _____________________
ParentSignature Date
LAUSDSECTION:
Notes:__________________________________________________________________________
AssessedBy:_____________________________________Date:_______________________
Rev.4/2019
LOSANGELESUNIFIEDSCHOOLDISTRICT
EARLYCHILDHOODEDUCATION
SELFCERTIFICATIONOFINCOME
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signature
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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.
or
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
y
2015
)
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signature
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signature
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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/
pm
am/
pm
am/
pm
am/
pm
am/
pm
am/
pm
am/
pm
End
Time:
am/
pm
am/
pm
am/
pm
am/
pm
am/
pm
am/
pm
am/
pm
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
m.
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
CenterName:_ ________________________
___________________
Email: ________________________
Address:, _______________________________Phone:
(___)-__________Fax:(___)-_____________
CHILDSECTION
Child(ren)beingreferredforEarlyChildhoodEducatio nServices:
ChildName
:_____________________________________
ChildName
:__________________________________
Birthdate:________________ Birthdate:________________
Livingwith:Parent/GuardianName:________________
_______________________
Isthechildinanoutofhomepla cement?YesNo Ifyes,childislivingwith:
Relative‐relationship:________________
____FosterParent Other(describe)_________________
Probabledurationofservices*:______________ ____________Hourscareneeded:_____________________
*Nottoexceed12monthsforchildprotectiveservicesorchildatriskofabuse,neglectorexploitation
DCFSREFERRALSECTION
ForusebyLosAngelesCountyDepartmentofChildrenandFamilyServicesonly
I certify that the child(ren) is receiving child protective services and child care and development services are a necessary
componentofthechildprotectiveservicesplan.
Ialsocertify thatitisnecessary to waive any family feeandincomeinformation will not be required from thefamily. Fee
exemptions cannot be granted beyond 12 months regardless of whether the child continues to receive child protective
services.The12monthtimelimitisacumulativetotal.
If Early Childhood Education services have continued for 12 months, I certify that the family continues to receive child
protectiveservicesandthatchildcareanddevelopmentservicesarepartofthecaseplan.
DCFSCaseNumber:______________________________
________________________________________________________________ _______________
DCFSRepresentativeName/Title Signature Date
Address:______________ ________________Phone:_________________Email:__
_________________________
ATRISKREFERRALSECTIONForusebyallorganizations/entitiesotherthanDCFS
IcertifythatIamalegallyqualifiedprofessionalfromaleg
al,medical,socialserviceagency,oremergencyshelterandthat
childcareservicesarerequiredtoreduceoreliminatetheriskofabuse,neglectorexploitationofthechild(ren).Iunderstand
thattheseservicesarelimitedto12months.
Ialsocertifythatitisitisnecessarytowaiveanyfamilyfeeforthe12monthsandincomeinformationwillnotberequired
fromthefamily.
ReferringAgency:______________ ___________________ CaseNumber:__________________
____________________________________ __________ _____________________ ________________
ReferringProfessionalName/Title Signature Date
Address:______________ ________________ Phone:______________
Email:___________________________
Form83.66(Rev.06/19)
LOSANGELESUNIFIEDSCHOOLDISTRICT
EARLYCHILDHOODEDUCATIONDIVISION
CHILD PROTECTIVE SERVICES / AT RISK REFERRAL
LAUSDSECTION:
Nameofparent:FamilyID:____________
Effectivedateofseekingemployment:
Californiastatelaw(5CCR18086.5)requiresthateligibilityforseekingemploymentislimitedto12
months.
Youwillusethemaximumnumberofdaysallowableon_______________________.Ifbythatdate
youhavenotsecuredemployment,childdevelopmentservicestoyourfamilymaybeterminated.
PARENTSECTION:
1. Please indicatetheactivitiesyouwillusetoactivelyseekemployment:
Lookforjobsinthenewspaper
Makephonecalls
Usetheinternet
Writeandsendresumes
Applyforinpersoninterviews
Applytoanemploymentagency
Visitcollegeplacementcenter
Godoortodoor
GototheEmploymentDevelopmentDepartment(UnemploymentOffice)
Other
2. Pleaseindicateifyouwouldlike:

Asetschedule(samehourseachday,nottoexceed30hourseachweek)

Avariableschedule(variedhoursbaseduponseekingemploymentactivities,notto
exceed30hourseachweek)
Ifyouwouldlikeafixedschedule,indicatethehoursanddaysoftheweekyouwilluseto
activelyseekemployment:
HOURS MONDAY TUESDAY WEDNESDAY THURSDAYFRIDAY
FROM:

TO:

IdeclareunderpenaltyofperjurythatIamseekingemploymentandthattheabove
informationistrueandcorrecttothebestofmyknowledge.IunderstandthatImay
beaskedtodocumentmyactivitieseachweek.Iwillnotifythecenterimmediately
ifthereisanychangeinmyemploymentstatus.
_______________________________________________ _____________________
ParentSignatureDate
BUL4363.0Rev.04/2018
LOSANGELESUNIFIEDSCHOOLDISTRICT
EARLYCHILDHOODEDUCATION
SEEKINGEMPLOYMENTAGREEMENT
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.
X
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
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