Fillable RESIDENCY DECLARATION (Berryessa Union School District)

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RESIDENCY DECLARATION (Berryessa Union School District)

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Revised 2/5/2019
Berryessa Union School District - 1376 Piedmont Road * San Jose, CA 95132 * 408-923-1800
Every Child Has The Right To A Free Public Education
2019-2020 Student Enrollment Information
New Students Entering Transitional Kindergarten, and Kindergarten through 8
th
grade
The first day of school is Monday, August 19, 2019
Due to space availability, students who do not attend class on this date, will risk being dropped from enrollment* and/or overloaded to another
elementary school.
*Students who are dropped from enrollment, will be required to repeat the entire enrollment process over again to be reenrolled.
Enrollment for the 2019-2020 school year, will begin in mid-February. Parents may enroll their child to our district on-line
(www.berryessa.k12.ca.us), or by printing and completing an enrollment packet, which is also available on our district web page
(www.berryessa.k12.ca.us).
To enroll your child, you must attend the below date that corresponds to your child’s resident home school family, and bring either your on-line
confirmation or a completed registration packet and provide the proper required documents to finalize the enrollment process. **
Please note, your child does not need to attend when you finalize your enrollment.
Currently enrolled Berryessa students in grades TK, and 5th, do not need to re-enroll for Kindergarten and 6
th
grade. Students will automatically
attend their resident elementary/middle school.
New student enrollment for TK and Kindergarten through 8
th
grade will be held on the following evenings:
Early Opportunities for Enrollment
Date Time Place
Piedmont Family Schools: March 7 (Thursday) 4:00 p.m. - 6:30 p.m. District Office
(Piedmont, Noble, Summerdale,
Toyon & Vinci Park)
Sierramont Family Schools: March 14 (Thursday) 4:00 p.m. - 6:30 p.m. District Office
(Sierramont, Cherrywood,
Majestic Way & Ruskin)
Morrill Family Schools: March 21 (Thursday) 4:00 p.m. - 6:30 p.m. District Office
(Morrill, Brooktree,
Laneview & Northwood)
Incomplete packets will not be accepted and you will be required to return at one of the below dates to finalize the registration. All required
vaccines and tests must be given and properly recorded for age by a doctor or clinic.
All School Families
Date Time Place
March 25 - June 21, 2019 9 a.m. - 1 p.m. Resident Home School
June 24 - Aug 1 (Monday -Thursday only) 9 a.m. - 1 p.m. ONLY District Office (9 a.m. – 1 p.m. ONLY)
Beginning August 5, 2019 9 a.m. - 1 p.m. Resident Home School
**Please read the “PARENT CHECKLIST” page of the student enrollment packet very carefully in order to ensure that you bring all necessary
documents to successfully complete the registration process.
Brooktree Elementary School
1781 Olivetree Drive - San Jose, CA 95131
(408) 923-1910
Noble Elementary School
3466 Grossmont Drive - San Jose, CA 95132
(408) 923-1935
Summerdale Elementary School
1100 Summerdale Drive - San Jose, CA 95132
(408) 923-1960
Cherrywood Elementary School
2550 Greengate Drive - San Jose, CA 95132
(408) 923-1915
Northwood Elementary School
2760 East Trimble Road - San Jose, CA 95132
(408) 923-1940
Toyon Elementary School
995 Bard Street - San Jose, CA 95127
(408) 923-1965
Laneview Elementary School
2095 Warmwood Lane - San Jose, CA 95132
(408) 923-1920
Piedmont Middle School
955 Piedmont Road - San Jose, CA 95132
(408) 923-1945
Vinci Park Elementary School
1311 Vinci Park Way - San Jose, CA 95131
(408) 923-1970
Majestic Way Elementary School
1855 Majestic Way - San Jose, CA 95132
(408) 923-1925
Ruskin Elementary School
1401 Turlock Lane - San Jose, CA 95132
(408) 923-1950
Morrill Middle School
1970 Morrill Avenue - San Jose, CA 95132
(408) 923-1930
Sierramont Middle School
3155 Kimlee Drive - San Jose, CA 95132
(408) 923-1955
BERRYESSA UNION SCHOOL DISTRICT
1376 Piedmont Road San Jose, CA 95132
Visit our website for additional information: www.berryessa.k12.ca.us
2019 – 2020 PARENT CHECKLIST
NOTE: A parent or legal guardian is required to sign the enrollment papers. It is essential for you to bring a Valid
Driver’s License or Valid Identification Card with you when you enroll your child. A driver’s license will not
be accepted as proof of residence. P. O. Boxes are not accepted as a residence address. It is NOT necessary for
your child to be present at time of enrollment.
The following documents are required to enroll your child for school. Please bring all required documents at time
of enrollment, and use this checklist to assist you in making sure all information is complete. You may contact
your neighborhood school if assistance is needed in completing any of these forms.
1. Berryessa Union School District Residence Verification (check one)
Homeowners - Your Proof of Ownership AND one other document as listed on next page.
Renters - Your Lease/Rental Agreement AND one other document as listed on next page.
All Others For Family Affidavit (located in this packet on the back of Residency Declaration),
Parent/Guardian registering the student(s) must provide two (2) pieces of mail with their name and
current address on it (government papers such as; tax papers, state assistance verification; and a bill
such as cell phone, credit card, medical, insurance). The Family Affidavit (Part 4 of the
Residency Declaration form) is required to be renewed annually and families may expect a
verification visit/check from district staff.
2. Original Child’s Age Verification Documentation and 1 copy (Birth Certificate preferred).
3. Original Child’s Immunization Record from Health Care Provider and 1 copy
Record must be updated by doctor or clinic with all required vaccines and tests properly recorded for
age. Please see Parents’ Guide to Immunizations attached in packet. Documentation of TB screening
assessment by student’s health care provider
4. Residency Declaration (and Part 4 Family Affidavit section on backside, if required)
5. Enrollment Forms, 2 pages
If your child has an IEP or 504 Plan, you must provide a current copy with your registration packet, so
that your child can be appropriately placed.
Please provide a current copy of your child’s state testing results if you have it available.
6. Home Language Survey
7. Understanding School Assignment Form
8. Student Media Release Form
9. Student Use of Technology Acknowledgement Form
10. Oral Health Assessment/Waiver Request Form (TK, Kindergarten and 1
st
grade only).
11. Report of Health Examination for School Entry (preferred for Kindergarten, required for 1
st
grade).
Please see INSTRUCTIONS FOR ENROLLMENT, item #3.
12. Medical Statement to Request Special Meals and/or Accommodations (to be completed if child has a
food allergy/intolerance)
13. SCC Public Health Department, TB Risk Assessment for School Entry
14. Parent/Guardian Valid Driver’s License or Valid Identification Card
INSTRUCTIONS FOR ENROLLMENT
1. RESIDENCE VERIFICATION:
If you own
If you rent
Deed of Trust, Grant Deed, Property Tax Bill
(or payment receipt), Mortgage Statement, Es-
crow Letter, Tax Assessment Card
Current Lease or Rental Agreement
(or payment receipt)
All others you must provide:
When a student and his/her parents/guardians reside with a party who lives within the Berryessa Union School District’s
boundaries (rent a room, share a home, live with relative) a Family Affidavit must be completed. Parent/Guardian regis-
tering the student(s) must provide two (2) pieces of mail with their name and current address on it (government papers
such as; tax papers, state assistance verification; a bill such as cell phone, credit card, medical insurance).
When only the student resides with a party (not the student’s parents) who lives within the Berryessa Union School Dis-
trict’s boundaries, a Caregiver’s Affidavit must be completed.
Both of these affidavits require that the residence be on a full-time basis, Monday through Thursday and are required to
be renewed annually.
Owner/Renter signing Family Affidavit must provide residence verification as stated above.
If, at any time, a question is raised about a student’s residence, the District will undertake an investigation of the stu-
dent’s actual residence. If it is found that the situation is not as stated by the parents/guardians, the student will be im-
mediately un-enrolled and then must enroll at their appropriate school or home district. (AR 5101.1) Berryessa Union
School District reserves the right to verify residence. It is the policy of the Berryessa Union School District that all new
students registering in the district and students who change their residence while attending school in the district provide
proof of residence within the boundaries of the Berryessa Union School District (BUSD).
2. AGE VERIFICATION:
One of the following ORIGINAL official documents and ONE PHOTOCOPY must be brought for enrollment: (Ed.
Code, Section 48000) containing the student’s first and last name, date of birth, and gender.
Certified Birth Certificate (PREFERRED), Baptism Record, Passport (Visa’s are not acceptable), Hospital Record,
School Transcript.
California Law and Board Policy permit the enrollment in kindergarten of those children who will be 5 years old on/or
before September 1 of the current school year (Ed. Code, § 48000). Children entering Berryessa schools from another
country will be assigned to their age appropriate grade level. If your child is transferring from another school, you may
bring age verification from his/her previous school.
If your child will turn 5 years old between September 2 and December 2, he/she is eligible to enroll in the Transitional
Kindergarten program. The availability of this program is dependent on state funding.
3. CALIFORNIA SCHOOL IMMUNIZATION RECORDS:
REPORT OF HEALTH EXAMINATION FOR SCHOOL ENTRY: (preferred for Kindergarten, required for 1
st
grade)
California state law requires children to have a health examination and submit a completed REPORT OF HEALTH
EXAMINATION FOR SCHOOL ENTRY (yellow form in this packet) 18 months prior to entering first grade. The
examination can be given up to six months before entering kindergarten, but NOT BEFORE March 1st of this year in
order to satisfy the 1
st
grade requirement. We recommend that parents submit the completed yellow form as part of the
kindergarten registration packet. However, if your child received their exam prior to March 1
st
of this year, they
will need to have another health exam prior to entering first grade. Please be sure to submit the yellow form to
your child’s school office prior to your child beginning the 1
st
grade.
Original Child’s Immunization Record from Health Care Provider and 1 Copy
If your child is enrolling from a previous school in California, a verified copy of the "California School Immunization
Record Form" may be brought from the previous school for enrollment.
Documentation of TB screening assessment by student’s health care provider
4. RESIDENCY DECLARATION (and Part 4 Family Affidavit section on backside, if required)
5. ENROLLMENT FORMS, 2 pages: This form must be completed in English.
It is important that all information is printed or typed. If your child attended another school prior to enrolling in the
Berryessa Union School District, be sure to include all previous school information so we may request your child's
past school records.
(If your child has an IEP or 504 Plan, you must provide a current copy with your registration packet, so that your child
can be appropriately placed.)
6. HOME LANGUAGE SURVEY
7. UNDERSTANDING SCHOOL ASSIGNMENT FORM
8. STUDENT MEDIA RELEASE FORM
9. STUDENT USE OF TECHNOLOGY ACKNOWLEDGEMENT FORM
10. ORAL HEALTH ASSESSMENT/WAIVER REQUEST FORM (TK, Kindergarten and 1st grade only).
11. REPORT OF HEALTH EXAMINATION FOR SCHOOL ENTRY (yellow) (preferred for Kindergarten, required
for 1
st
grade)
12. MEDICAL STATEMENT TO REQUEST SPECIAL MEALS AND/OR ACCOMMODATIONS (to be complet-
ed if child has a food allergy/intolerance)
13. SCC Public Health Department, TB Risk Assessment for School Entry
ATTENDANCE POLICY (GENERAL STATEMENT)
On-time daily attendance is a critical part for student achievement and academic success. Berryessa Union School District
adheres to strict attendance policies. Parents/Guardians are encouraged to schedule their vacation/trips around the school
calendar. During the first week of school, you will be receiving a detailed Attendance Agreement defining excused and
unexcused absences and Berryessa attendance policy.
Schools of Choice
Parents in the Berryessa Union School District may select to have their child attend a school other than their designated
neighborhood school, if space is available, through a transfer process. “Request For Interdistrict Attendance Permit” (trans-
fer request) forms are available at the District Office and at school offices throughout the district. This request allows stu-
dents to attend a school outside of the Berryessa Union School District.
ADDITIONAL DOCUMENTATION CAN AND MAY BE REQUESTED: MEETING ALL OF THE ABOVE RE-
QUIREMENTS MAY NOT SATISFY THE DISTRICT’S REASONABLE DOUBT REGARDING A STUDENT’S
AGE, PARENT/GUARDIAN STATUS OR RESIDENCY.
2019-2020
RESIDENCY DECLARATION
BERRYESSA UNION SCHOOL DISTRICT, 1376 Piedmont Rd, San Jose, CA 95132
THIS FORM MUST BE COMPLETED, SIGNED AND SUBMITTED WITH PROOF OF RESIDENCY
PART 1: STUDENT AND PARENT/LEGAL GUARDIAN INFORMATION
______________________________ ________________________ _____________ ______________________ ______________ _________
Student’s Last Name Student’s First Name Grade Birth Date Age M/F
____________________________________ ______________________________________ _________________________________________
Parent/Legal Guardian’s Last Name Parent/Guardian’s First Name Parent/Legal Guardian’s Home Phone/Cell Phone
_______________________________________________ ___________ ______________________________ ______________ __________________
Parent/Legal Guardian’s Current Street Address Apartment # City State Zip
How long has the student lived full time at the above listed address? ______________
Type of Dwelling in which Family Resides:
______ Single Family (house, condo, mobile home, etc) (200) ______ Foster Family/Kinship (210) ______ Doubled–Up (120) _______ Motel/Hotel (110)
______ Shelter/Transitional Housing Program (100) ______ Unsheltered (car/campsite) (130) ______ Other _________________________________
PART 2: ADDITIONAL ADDRESS HISTORY
Please provide the previous address you or your student have lived, if less than 3 years at current address
_______________________________________________ ___________ ______________________________ ____________ __________________
Previous Street Address Apartment # City/Country if not in USA State Zip
Please provide the address of other property you (or spouse) currently own, rent, or lease in the U.S.
_______________________________________________ ___________ ______________________________ ____________ _________________
Street Address of additional location Apartment # City State Zip
PART 3: DECLARATION OF UNDERSTANDING
Initial next to each statement to indicate your understanding
______California Education Code (Section 48200) and District Administrative Regulation 5111 require that a student be enrolled in and attend the
school that is within the district in which the student’s parent(s) or legal guardian(s) reside(s).
______My Student resides with me full time (or legally mandated residency of 50% or more) at the address listed above, which is my full time
primary residence. I agree to notify the District, within 15 calendar days, if the student or I, move.
______ Berryessa Union School District will actively investigate all cases where it has reason to believe false information has been provided on this
statement or to any school/district official.
______ I understand that home visitation and/or residency verification is part of a periodic process when residency is established in the Berryessa
Union School District. I also understand that the District staff may verify residency status, which may include home visits and investigations.
______ The District may refer cases in which false information has been provided to the County District Attorney for further action and/or file civil
action to recover damages incurred as a result of providing false information.
______ Persons who provide or solicit false information are subject to criminal prosecution for perjury, which is punishable by fine and/or prison
(up to 4 years) and may be found civilly liable for fraud, negligent misrepresentation, or negligence. [Civil Code § 1709] [Family Code §
6552; Penal Code § 118 and 126]
______ I am aware and understand that should this statement be found to be false, I could be held liable for the expense of education for my
student at a cost based on the state’s revenue limit per school year.
______ In the event investigations that reveal that students have enrolled on the basis of providing false information, they will be dropped from
enrollment and required to transfer to his/her resident school.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. In accordance with State
Compliance I have attached the required documentation as proof of residence for enrollment.
___________________________________________________________ ________________________ ___________________________
Signature of Parent/Legal Guardian Date Daytime Telephone
OFFICE USE ONLY
__________________________________ ________________________________ _____________________________ _________________________
List what was shown (1) List what was shown (2) Mail verified by: Date
click to sign
signature
click to edit
Page 2 of 2
REQUIRED DOCUMENTS FOR PROOF OF RESIDENCY VERIFICATION
If you own If you rent
One of the following documents in parent's name, showing
residency property address where the student physically resides.
P.O. Boxes are not accepted as a residence address.
Deed of Trust, Grant Deed, Property Tax Bill (or payment
receipt), Mortgage Statement, Escrow Letter,
Tax Assessment Card
Current Lease or Rental Agreement
(or payment receipt)
and one of the following documents in parent's name showing residency property address
Current PG&E Bill, Utility Service Contract (or statement/payment receipt), Pay Stub, W-2 Form,
Voter Registration, valid CA Vehicle Registration, correspondence from a Government agency.
PART 4: (FAMILY AFFIDAVIT) TO BE COMPLETED BY OWNER/LANDLORD IF LIVING WITH ANOTHER FAMILY
Initial next to each statement below to indicate your understanding and provide Proof of Residency documents in owner/landlord’s name
______________________________ ________________________ _____________ ______________________ ______________ _________
Student’s Last Name Student’s First Name Grade Birth Date Age M/F
____________________________________ ______________________________________ _________________________________________
Parent/Legal Guardian’s Last Name Parent/Guardian’s First Name Parent/Legal Guardian’s Home Phone/Cell Phone
_______________________________________________ ___________ ______________________________ ______________ __________________
Parent/Legal Guardian’s Current Street Address Apartment # City State Zip
The above named occupants live full-time in a residence owned/leased by me. I understand that if this student/family are not actually living with
me (or living in the residence owned/leased by me) at this address on a full-time basis, the enrollment of this student in the Berryessa Union School
District will cease. I hereby agree to notify school officials immediately if there is any change of address for the student(s) living in my residence. I
have provided proof of my residence at time of enrollment/renewal (or change of address) within the Berryessa Union School District boundaries.
One of the following documents in property owner’s name, showing residency property address, such as:
Deed of Trust, Grant Deed, Property Tax Bill (or payment receipt), Mortgage Statement, Escrow Letter,
Tax Assessment Card, Current Lease or Rental Agreement that must state able to sublet.
And one of the following documents in property owner’s name, showing residency property address, such as:
Current PG&E Bill, Utility Service Contract (or statement/payment receipt), Pay Stub, W-2 Form,
Voter Registration, valid CA Vehicle Registration, correspondence from a Government agency.
I understand intentionally giving false information is considered fraudulent and falsification of information will be justification for student(s)
being withdrawn from school. Berryessa Union School District reserves the right to verify residence. Families may expect a verification
visit/check from district staff.
______ I am the Owner/Landlord of the property at the above residence.
______ I attest that the student and parent listed above, reside at the above residence.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
___________________________________________________________
Owner/Landlord Name (please print)
___________________________________________________________ _________________________ ___________________________
Signature of Owner/Landlord Date Daytime Telephone
PARENT/GUARDIAN REGISTERING THE STUDENT MUST PROVIDE TWO PIECES OF MAIL WITH THEIR NAME AND CURRENT ADDRESS ON IT, SUCH AS: VEHICLE
REGISTRATION, INCOME TAX PAPERS, STATE ASSISTANCE VERIFICATION, PAY STUB, W-2, CELL PHONE BILL, CREDIT CARD STATEMENT, MEDICAL INSURANCE.
OFFICE USE ONLY
__________________________________ ________________________________ ____________________________ _________________________
List what was shown (1) List what was shown (2) Mail verified by: Date
click to sign
signature
click to edit
Page 1 of 2
OFFICE USE ONLY:
Birth Verification
B. C. P B. R.
H. R. S. T.
Berryessa Union School District, 1376 Piedmont Rd, San Jose, CA 95132
STUDENT ENROLLMENT FORM
PLEASE PRINT - ALL AREAS MUST BE COMPLETE
STUDENT/FAMILY INFORMATION
____________________________ _______________________ ________________________ ________________________
Student’s Legal Last Name Legal First Name Legal Middle Name Other Name Used
________________________________ ____________________ ____________ _____________________ Grade: ________
Student’s Home Address City Zip Code Home Phone Number
Student Date of Birth Student Place of Birth: Male ________
______/______/______ __________________ _______ _______________ Female _______
Month Day Year City State Country
Father/ Guardian – Relationship to Student: _____________________ Student lives with Father/Guardian? Yes No
__________________ __________________ ______________________ _________________________
Last Name First Name Cell Phone Number E-mail Address
_______________________________________ ____________________ ____________ - ________ __________________
Home Address (if different from student) City Zip Code Home Phone Number
Not High School Grad High School Grad Some College and/or 1-2 yrs Community College 4 yr College Grad Grad School/PostGrad
______________________________________________________________________________________________________________________________
Mother/ Guardian – Relationship to Student: _____________________ Student lives with Mother/Guardian? Yes No
_____________________ ______________________ __________________________ _______________________________
Last Name First Name Cell Phone Number E-mail Address
_______________________________________ ____________________ ____________ - ________ __________________
Home Address (if different from student) City Zip Code Home Phone Number
Not High School Grad High School Grad Some College and/or 1-2 yrs Community College 4 yr College Grad Grad School/PostGrad
TYPE OF DWELLING (federally mandated)
Single Family (house, condo, mobile home, etc) (200) Shelter/Transitional Housing Program (100)
Temporarily Doubled-Up (120) Foster Family/Kinship (210)
Motel/Hotel (110) Unsheltered (car/campsite) (130) Other ______________________________
SPECIAL PROGRAMS: Has your child received assistance from or participated in any of the following programs:
Language/Speech/Hearing (LSH) Resource Specialist Program (RSP) 504 Plan Special Day Class (SDC)
Individual Education Plan (IEP)* Modified/Adaptive Physical Ed Retained in Grade: ________
* Must provide copy of current IEP or 504 Plan
PREVIOUS SCHOOL/PRESCHOOL INFORMATION: Last Day of Attendance: _____/_____/_____
_______________________ _________________ ______________________ _____________ _____ _________ _____________
Previous School Attended School District School Address City State Zip Code Phone Number
Is student Hispanic or Latino? (Must select one) No, not Hispanic or Latino Yes, Hispanic or Latino
Persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
Please indicate your primary race/ethnicity by marking only one “P”.
Indicate as many other race/ethnicity as appropriate by indicating with an “X”. Must select at least one.
___American Indian or Alaska Native ___Black or African American ___White
Asian: ___Chinese ___Japanese ___Korean ___Vietnamese ___Asian Indian ___Laotian ___Cambodian ___Filipino ___Other Asian
Native Hawaiian or Other Pacific Islander: ___Hawaiian ___ Guamanian ___Samoan ___Tahitian ___Other Pacific Islander
What other language would you like written correspondence in? English Chinese Spanish Vietnamese
MOBILITY: (Required for State Testing Reports) PLEASE NOTE: The below questions do not pertain to Preschool
What grade did/will your child first attend THIS SCHOOL in Berryessa Union School District (Grades TK-8)? Grade:_____
What grade did/will your child first attend BERRYESSA UNION SCHOOL DISTRICT (Grades TK-8)? Grade:_____
What date did/will your child first attend a PRIVATE OR PUBLIC SCHOOL in CALIFORNIA (Grades TK-8)? Month_____Day_____Year _____
What date did/will your child attend a PRIVATE OR PUBLIC SCHOOL in the UNITED STATES (Grds TK-8)? Month_____Day_____Year _____
First Day of Attendance: ___________________ OFFICE USE ONLY
Neighborhood School: ____________________
Teacher: ________________________ Date Received: __________
Student ID: ______________________ Time Received: __________
Page 2 of 2
Student’s Last Name: _____________________ First: _____________________ DOB: ___________
HEALTH INFORMATION:
Health Care Provider: ____________________________________________ Group #: ___________________
Student’s Doctor Name: __________________________________________ Phone: ____________________
Student’s Dentist Name: __________________________________________ Phone: ____________________
Does your child require corrective lenses? Yes No
Does your child have a health condition? Yes No (If any boxes are checked, please explain below)
Allergies - life threatening Hearing Problems Orthopedic Condition
Asthma Heart Problems Other Significant Health Concerns
Diabetes Limited Physical Activity Seizure Disorder
Neurological Condition Vision Problems - Eye disease such as glaucoma, cataracts,
color blindness, other (please explain below)
Please explain: _____________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
* FOOD ALLERGIES REQUIRE FORM (attached to packet) “MEDICAL STATEMENT TO REQUEST
SPECIAL MEALS AND/OR ACCOMMODATIONS”
Does your child take medication on a regular basis? Yes No Is it required during school day? Yes* No
If yes, list medication(s): _________________________________ __________________________________
* If medication is taken during school hours, please see school office for the “PERMIT TO TAKE MEDICA-
TION IN SCHOOL” form (or print one from our district website). This form must be renewed annually.
Father/ Guardian Work Phone: ____________________ Company Name: ____________________ Occupation: _________________
Mother/Guardian Work Phone: ____________________ Company Name: ____________________ Occupation: _________________
EMERGENCY CONTACT: DO NOT LIST PARENTS/GUARDIANS WHO ARE LISTED ON THE FRONT OF THIS FORM:
In case of my child’s illness, injury or the event of a major disaster (e.g., earthquake, flood) and the school is unable to reach me, I give my consent
to call or release my child to any of the following persons listed below
.
Name Address, City Telephone Relationship to Student
_______________________ _____________________________ _______________ ___________________
_______________________ _____________________________ _______________ ___________________
_______________________ _____________________________ _______________ ___________________
OTHER CHILDREN LIVING IN THE HOME, AGES 1 DAY TO 20 YRS OLD:
Name Gender Birth Date Grade School Relationship to Student
___________________ ______ ____________ ______ _________________ ___________________
___________________ ______ ____________ ______ _________________ ___________________
___________________ ______ ____________ ______ _________________ ___________________
RESIDENT VALIDATION:
I verify that my child meets the school resident requirements established by Berryessa Union School District. I have substantiated this requirement by providing the requested documen-
tation. I understand that if it is found that the student is not living at the residence as stated and/or falsification of information, my child will immediately be enrolled at the appropriate
district school or home district. If I change my residence while attending school in the district, I will be required to provide proof of residence within the boundaries of the Berryessa
Union School District. I hereby certify that the STUDENT/FAMILY INFORMATION provided on pages 1 and 2 is accurate and I understand that intentionally giving false information
is considered to be fraudulent. I, the (parent or legal guardian) of this child, certify that all information on this enrollment form is true and correct.
Parent/Guardian Signature: ________________________ Date: __________
OFFICE USE ONLY: E/R Identified: P : S : O
Residence verified by: _________________________________ School Year: 2019-2020
Resident verification: _______________________________________ AND ________________________________________
(List what was shown) (List what was shown)
Valid ID: (check one) Driver’s License OR Identification Card
click to sign
signature
click to edit
BERRYESSA UNION SCHOOL DISTRICT
HOME LANGUAGE SURVEY
Name of Student: __________________________ ______________________ _____________ _________
Surname / Last Name First Given Name Second Given Name
Student’s Home Address: _________________________________________________ _____________ ____
School: _________________________ Birthdate: ___________________ Grade: ___________________
Phone Number: Home: _____________________________ Cell: _______________________ ____________
Directions to Parents and Guardians:
The California Education Code contains legal requirements which direct schools to determine the language(s)
spoken in the home of each student. This information is essential in order for the school to provide adequate
instructional programs and services.
As parents or guardians, your cooperation is requested in complying with this legal requirement. Please respond
to each of the four questions listed below as accurately as possible. For each question, write the name(s) of the
language(s) that apply in the space provided. Please do not leave any question unanswered.
1. Which language did your child learn when he/she first began to talk? ________________
2. Which language do you (the parents or guardians) most frequently
use when speaking with your child? ________________
3. Which language does your child most frequently speak at home? ________________
4. Which language is most often spoken by adults in the home?
(parents, guardians, grandparents, or any other adults) ________________
5. Has your child ever had a California English Language Development Test? (CELDT) ________________
Yes* or No
*If yes, which school district? __________________________________
*IF CHINESE, PLEASE SPECIFY WHICH DIALECT: ________________
Please sign and date this form in the spaces provided below.
Thank you for your cooperation.
_________________________________ _______________________
Signature of Parent or Guardian Date
__________________________________________________________________________________________
Office use only:
CELDT Appointment: Date: ______________________ Time: ____________________
click to sign
signature
click to edit
GRADE NUMBER OF DOSES REQUIRED OF EACH IMMUNIZATION
1, 2, 3
K-12 Admission 4 Polio
4
5 DTaP
5
3 Hep B
6
2 MMR
7
2 Varicella
(7th-12th)
8
1 Tdap
7th Grade
Advancement
9,10
1 Tdap
8
2 Varicella
10
CALIFORNIA IMMUNIZATION REQUIREMENTS FOR
K – 12
TH
GRADE (including transitional kindergarten)
DTaP/Tdap = diphtheria toxoid, tetanus toxoid, and acellular pertussis vaccine
Hep B = hepatitis B vaccine
MMR = measles, mumps, and rubella vaccine
Varicella = chickenpox vaccine
INSTRUCTIONS:
California schools are required to check immunization records for all new student admissions at TK /Kindergarten
through 12th grade and all students advancing to 7th grade before entry.
UNCONDITIONALLY ADMIT a pupil whose parent or guardian has provided documentation of any of the following
for each immunization required for the pupil’s age or grade as dened in table above:
• Receipt of immunization.
• A permanent medical exemption in accordance with 17 CCR section 6051.
• A personal beliefs exemption (led prior to 2016) in accordance with Health and Safety Code section 120335.
CONDITIONALLY ADMIT any pupil who lacks documentation for unconditional admission if the pupil has:
• Commenced receiving doses of all the vaccines required for the pupil’s grade (table above) and is not currently
due for any doses at the time of admission (as determined by intervals listed in Conditional Admission Schedule,
column entitled “EXCLUDE IF NOT GIVEN BY”), or
• A temporary medical exemption from some or all required immunizations (17 CCR section 6050).
IMM-231 (11/18) California Department of Public Health • Immunization Branch • ShotsForSchool.org
1. Requirements for K-12 admission also apply to transfer
pupils.
2. Combination vaccines (e.g., MMRV) meet the requirements
for individual component vaccines. Doses of DTP count
towards the DTaP requirement.
3. Any vaccine administered four or fewer days prior to the
minimum required age is valid.
4. Three doses of polio vaccine meet the requirement if one
dose was given on or after the fourth birthday.
5. Four doses of DTaP meet the requirement if at least one
dose was given on or after the fourth birthday. Three doses
meet the requirement if at least one dose of Tdap, DTaP, or
DTP vaccine was given on or after the 7th birthday. One
or two doses of Td vaccine given on or after the seventh
birthday count towards the requirement.
6. For seventh grade admission, refer to Health and Safety
Code section 120335, subdivision (c).
7. Two doses of measles, two doses of mumps, and one dose
of rubella vaccine meet the requirement, separately or
combined. Only doses administered on or after the rst
birthday meet the requirement.
8. For 7th-12th graders, at least one dose of pertussis-contain-
ing vaccine is required on or after the seventh birthday.
9. For children in ungraded schools, pupils 12 years and older
are subject to the seventh grade advancement require-
ments.
10. The varicella requirement for seventh grade advancement
expires after June 30, 2025.
CONDITIONAL ADMISSION SCHEDULE FOR GRADES K-12
Before admission a child must obtain the rst dose of each required vaccine and any subsequent doses that are
due because the period of time allowed before exclusion has elapsed.
DOSE EARLIEST DOSE MAY BE GIVEN EXCLUDE IF NOT GIVEN BY
Polio #2 4 weeks after 1st dose 8 weeks after 1st dose
Polio #3 4 weeks after 2nd dose 12 months after 2nd dose
Polio #4
1
6 months after 3rd dose 12 months after 3rd dose
DTaP #2 4 weeks after 1st dose 8 weeks after 1st dose
DTaP #3
2
4 weeks after 2nd dose 8 weeks after 2nd dose
DTaP #4 6 months after 3rd dose 12 months after 3rd dose
DTaP #5 6 months after 4th dose 12 months after 4th dose
Hep B #2 4 weeks after 1st dose 8 weeks after 1st dose
Hep B #3 8 weeks after 2nd dose 12 months after 2nd dose and
at least 4 months after 1st dose
MMR #2 4 weeks after 1st dose 4 months after 1st dose
Varicella #2 Age less than 13 years:
3 months after 1st dose
4 months after 1st dose
Age 13 years and older:
4 weeks after 1st dose
8 weeks after 1st dose
1. Three doses of polio vaccine meet the requirement if one dose was given on or after the fourth birthday.
2. If DTaP #3 is the nal required dose, DTaP #3 should be given at least six months after DTaP #2, and pupils should be
excluded if not given by 12 months after second dose. Three doses meet the requirement if at least one dose of Tdap,
DTaP, or DTP vaccine was given on or after the seventh birthday. One or two doses of Td vaccine given on or after the
seventh birthday count towards the requirement.
Continued attendance after conditional admission is contingent upon documentation of receipt of the
remaining required immunizations. The school shall:
• review records of any pupil admitted conditionally to a school at least every 30 days from the date of
admission,
• inform the parent or guardian of the remaining required vaccine doses until all required immunizations are
received or an exemption is led, and
• update the immunization information in the pupil’s record.
For a pupil transferring from another school in the United States whose immunization record has not been
received by the new school at the time of admission, the school may admit the child for up to 30 school days. If
the immunization record has not been received at the end of this period,
the school shall exclude the pupil until the parent or guardian provides
documentation of compliance with the requirements.
CALIFORNIA IMMUNIZATION REQUIREMENTS FOR K-12
TH
GRADE (continued)
IMM-231 (11/18) California Department of Public Health • Immunization Branch • ShotsForSchool.org
Questions?
See the California
Immunization Handbook
at ShotsForSchool.org
Immunization Education
and Planning Program
IMMUNIZATION SERVICES
Immunization Services
in Santa Clara County
SCHOOL HEALTH CENTERS
•
Franklin McKinley School Center
645 Wool Creek Dr., San Jose, CA 95112
1.408.283.6051
•
Gilroy Neighborhood Health Clinic
•
7861 Murray Avenue, Gilroy CA 95020
1.408.842.1017
•
Overfelt Neighborhood Health Clinic
1835 Cunningham Ave., San Jose, CA 95122
1.408.347.5988
•
San Jose High Neighborhood Health Clinic
1149 Julian St., Bldg. H, San Jose, CA 95116
1.408.535-6001
•
Washington Neighborhood Health Clinic
100 Oak St., San Jose, CA 95110 1.408.295.0980
MAYVIEW COMMUNITY HEALTH CENTERS
•
Mayview Community Health Center
270 Grant Ave., Palo Alto, CA 94306
1.650.327.8717
•
Mayview Community Health Center
900 Miramonte Ave. 2
nd
floor, Mtn. View, CA
94040 1.650.965-3323
•
Mayview Community Health Center
785 Morse Ave., Sunnyvale, CA 94085
1.408.746.0455
PLANNED PARENTHOOD CLINICS
Call center for all Planned Parenthood clinics:
1.877.855.7526
•
Planned Parenthood, Blossom Hill
5440 Thornwood Dr., #G, San Jose, CA
95123
•
Planned Parenthood, Mountain View
225 San Antonio Rd., Mtn. View, CA 94040
•
Planned Parenthood, San Jose Rose Garden
1691 The Alameda, San Jose, CA 95126
•
Mar Monte Community Clinic
2470 Alvin Ave., #60, San Jose, CA 95121
GARDNER FAMILY HEALTH NETWORK
•
Alviso Health Center
1621 Gold St., Alviso, CA 95002 1.408.935.3949
•
CompreCare Health Center
3030 Alum Rock Ave., San Jose, CA 95127
1.408.272.6300
•
Gardner Health
Center
195 E. Virginia St., San Jose, CA 95112
1.408.998.8815
•
Gardner South County Health Center
7526 Monterey St., Gilroy, CA 95020
1.408.848.9400
•
St. James Health Center
55 E. Julian St., San Jose, CA 95112
1.408.918.2600
•
Gardner Downtown Health Center
725 E. Santa Clara St., #10, San Jose, CA 95112
1.408.794.0500
COMMUNITY CLINICS/HEALTH CENTERS
•
Asian Americans for Community Involvement
2400 Moorpark Ave., #319, San Jose, CA 95128
1.408.975.2763
•
Foothill Community Health Center, Gilroy Clinic
9460 No Name Uno, Suite 110, Gilroy CA 95020
1.408.729.9700
•
Foothill Community Health Center, Family Clinic
1066 South White Rd., #170, San Jose, CA 95127
1.408.729.9700
•
Foothill Community Health Center, Montpelier Clinic
2380 Montpelier Dr., #200, San Jose, CA 95116
1.408.254.1800
•
Foothill Community Health Center, Story Clinic
2880 Story Rd., San Jose, CA 95127
1.408.729-9700
•
Indian Health
Center, Meridian
1333 Meridian Ave., San Jose, CA 95125
1.408.445.3400
•
Indian Health Center, Silver Creek
1642 E Capitol Expy., San Jose, CA 95121
1.408.445.3400 x200
To see if your child is eligible for free or low cost children’s health insurance, please call:
•
Children’s Health Initiative
1.888.244.5222
•
Child Health & Disability Prevention Program
1.408.937.2250
•
Medi-Cal
Eligibility
1.877.962.3633
•
Santa Clara Valley Health & Hospital System
Valley Connection
1.888.334.1000
Santa Clara County Public Health Department Immunization Program | 1.408.792.5007 | www.sccphd.org | updated 2-10-17
Coverage and
care are free
or low cost
Medi-Cal is free for children whose
household meets certain income
requirements. Other families,
depending on their income, may have
a small monthly fee. For all children,
Medi-Cal coverage opens the door to
free preventive care and treatment,
including medical, vision, dental, and
mental health services. Getting regular
preventive care, like checkups and
screenings, makes it possible to identify
and treat health problems before they
become more serious conditions.
ALL CHILDREN,
regardless of
immigration status,
are eligible for
Medi-Cal coverage.
Health coverage and care are an
important part of making sure children
and youth succeed in school and life.
As of May 16, 2016, health coverage
through Medi-Cal is available to all
undocumented children under 19
years old, whose families meet the
income requirements. For example,
all children in a family of four that has
a monthly income of $5,387 will qualify
for coverage.
Apply
any time of
the year
You can enroll in Medi-Cal any time of
the year. You can apply over the phone,
through a mail-in application, or in
person at your local county human
services office or local clinic. Get help
finding a clinic at www.localclinic.net or
by calling (855) 899-7587.
Bring what
you need
When you apply for Medi-
Cal, bring as
many of the following items as you can:
E
Proof of Identity (any passport or
photo ID)
E
Proof of Income (current pay stub
or bank statement)
E
Proof of Residency (telephone or
electric bill)
E
Medi-Cal cards of other family
members, if applicable
* Not all items are needed to enroll;
more examples are accepted.
HEALTHY
KIDS MAKE
BETTER
LEARNERS.
IMMIGRANT FAMILIES
can enroll their children in Medi-Cal
without worrying how personal
information, including their
immigration status, will be shared.
Personal information is safe and
protected and will NOT be shared
with immigration ocials or used
for immigration enforcement
purposes. Medi-Cal will only use
personal information to check
eligibility status for health coverage.
A PROJECT OF THE CHILDREN’S PARTNERSHIP
HEALTH
CARE
FOR ALL
FAMILIES
FOR MORE INFORMATION GO TO:
www.allinforhealth.org/health4allkids
© The Children’s Partnership, November 2016
The s of Health
Coverage for ALL K i d s
La cobertura medica y
el cuidado medico son
gratuitos o de bajo costo
Medi-Cal es gratuito para niños cuyas
familias cumplen con ciertos requisitos de
ingreso. Otras familias, dependiendo de su
ingreso, pueden tener una pequeña cuota
mensual. Para todos los niños, la cobertura
con Medi-Cal abre las puertas a cuidado
médico preventivo y tratamiento gratuitos,
incluyendo cuidado médico, de visión,
dental y servicios de salud mental. El obtener
cuidado médico preventivo regularmente,
como revisiones y visitas médicas
rutinarias, hace posible el identificar y
tratar problemas de salud antes de que se
conviertan en condiciones más serias.
TODOS los niños, sin
importar su estatus
migratorio, son elegibles
para cobertura con
Medi-Cal.
La cobertura médica y el cuidado médico
son importantes para asegurarse que
los niños y los jóvenes tengan éxito en
la escuela y en la vida. A partir del 16
de mayo de 2016, la cobertura médica
a través de Medi-Cal está disponible
para todos los niños indocumentados
menores de 19 años cuyas familias
cumplan con los requisitos de ingreso.
Por ejemplo, todos los niños en una
familia de cuatro personas que tenga un
ingreso mensual de $5,387 calificarán
para cobertura médica.
Solicite en cualquier
época del año
Usted puede inscribirse en
Medi-Cal en cualquier época del año.
Puede solicitar por teléfono, a través de
una solicitud por correo, o en persona en
la oficina local de servicios sociales del
condado. Obtenga ayuda para encontrar
una clínica en el siguiente sitio web
www.clinicalocal.net o llamando al
(855) 899-7587.
Traiga lo que se
necesita
Cuando solicite Medi-Cal
traiga, de los siguientes documentos, los
más que pueda:
E Comprobante de identidad
(cualquier pasaporte o identificación
con fotografía)
E Comprobante de ingreso (talón de
cheque o comprobante de cuenta de
banco más reciente)
E Comprobante de residencia (recibo
de teléfono o luz)
E Tarjetas de Medi-Cal de otros
miembros de la familia (según aplique)
* No todos los documentos anteriores se
necesitan para inscribirse; se aceptan
más ejemplos.
LAS FAMILIAS INMIGRANTES
pueden inscribir a sus hijos en
Medi-Cal sin preocuparse por cómo
se utilizará su información personal,
tal como su estatus migratorio. Los
datos personales están seguros y
protegidos y NO se compartirán con
ociales de inmigración; tampoco
se utilizarán para propósitos de
inmigración. Medi-Cal únicamente
utilizará su información personal
para vericar su elegibilidad para
cobertura médica.
LOS NIÑOS
SANOS
APRENDEN
MEJOR.
PARA MÁS INFORMACIÓN VISITE:
www.allinforhealth.org/health4allninos
© The Children’s Partnership, noviembre 2016
UN PROYECTO DE “THE CHILDREN’S PARTNERSHIP”
Asegúrate,
para el
bienestar de
tu familia
PUNTOS PRINCIPALES
relacionados con la cobertura
médica de TODOS los niños
What Does CHDP Offer?
The CHDP program helps to prevent or find
health problems through regular, no cost,
health check-ups. A check-up includes:
Health and developmental history
Physical exam
Needed shots
Oral health screening and routine
referral to a dentist starting by age 1
Nutrition screening
Behavioral screening
Vision screening
Hearing screening
Health information
Lab tests, which may include:
anemia, lead, tuberculosis, and other
problems, as needed
Referral to Women, Infants, and
Children (WIC) program for children
up to age 5
Other Services
If further health services are needed, we will
help you find them, including:
Dentists that accept Denti-Cal for
the care of your child’s teeth
Medical specialists, as needed
Mental and behavioral health
services, as needed
Diagnosis and treatment can be paid for
as long as your child has Medi-Cal.
In
f
orm
ation
For more information about CHDP,
transportation options, or for help setting
up an appointment, contact your local
CHDP office.
You can find your local CHDP office by
visiting the California Department of
Health Care Services website at:
www.dhcs.ca.gov/services/chdp
Regular health check-ups keep your
child healthy.
Health check-ups can also find
and treat problems before they
become serious
.
Edmund G. Brown, Jr.
Governor, State of California
PUB 183 (English, 9/15)
En
g
lish
Child Health and Dis
ab
ili
t
y
Prevention (CHDP) Pr
og
r
a
m
Medical and Dental
Health Check-Ups
FREE
For Babies, Children, and
Youth
Under age 21 with Full Scope
Medi-Cal or
Under Age 19 with Low Family
Income.
No Documentation
Required
Why Get Health Check-Ups?
Health check-ups are important for all children and youth. Health check-ups are a time to:
Find and address medical, dental, mental, and behavioral health problems
Get needed shots
Ask your doctor questions
Health check-ups can also be used for foster care, sports, camp, or school entry, as
needed.
Who is Eligible?
Children and youth up to age 21 who are
eligible for Medi-Cal. Children and youth
under age 19 with family incomes less than
or equal to 200% Federal Income
Guidelines are also eligible. Proof of
residence and income is not required
.
Babies and Toddlers
Birth Through
3 Years
Regular check-ups can keep your baby
happy and healthy. You can find out about
your baby’s growth, weight, and health, and
needed shots are given. At 1 year and 2
years, your baby should be tested for lead.
A test for anemia is also given. Your child
should see a dentist at least once a year
starting by age 1.
Dental
Please contact your local CHDP office
for assistance to find a Dentist who
accepts Denti-Cal. CHDP may also
assist with appointment scheduling
and transportation if necessary.
School Children
4
Through
12 Years
It is important to make sure your child is
healthy and ready for school. State laws
require children to be up to date on their
shots and get a health check-up.
School children will also get vision and
hearing screenings. If your child has not
had a lead test before, he/she should
have one by age 6 or before. Your child
should see a dentist at least once a year.
Vision & Hearing
The local CHDP office can provide
assistance to obtain vision and hearing
services if medically necessary.
Teens and Young Adults
13
Through
20 Years
Teens need health check-ups too! This is a
chance to make sure your teen is growing
and developing well. It is also a time for
you or your teen to ask the doctor any
questions. Extra health check-ups can be
given for sports and camp physicals. Your
child should see a dentist at least once
a year.
Mental Health, Autism and
Behavioral Services
Contact the local CHDP office for
assistance to access these services.
Berryessa Union School District
UNDERSTANDING SCHOOL ASSIGNMENT FORM
I understand that my child, _______________________________is not guaranteed
enrollment in his/her designated school of attendance
. If there is no space
available in his/her designated school, my child will be assigned to an overload
school in the district. If space is available, your child will be invited back the
following school year.
Enrollment to your child’s designated school of attendance is determined by the
date and time in which enrollment documents were submitted and considered
complete during central registration.
I understand that if a grade at my child’s designated school of attendance reaches
capacity, the student(s) selected to be assigned to another District school will be
determined on a “last in
, first out” basis.
I understand that if my child does not attend class on the first day of school he/she
may lose placement in the class/school and may be assigned to another school
within the District.
Printed Parent/Guardian Name: _________________________________________
Parent/Guardian Signature: ___________________________ Date: __________
Grade: _____________ Birthdate: _________________
Name of School: _________________________ Student Id: ________________
Designated School of Attendance is defined as:
A school designated by the District for your specific residence area.
LAST IN is defined by:
The date and time the completed enrollment packet is received by the
School/District.
PLEASE COMPLETE OTHER SIDE
Berryessa Union School District
STUDENT MEDIA RELEASE FORM
Dear Parents/Guardians,
Berryessa Union School District is proud of the many accomplishments of our
students and staff. Often, such accomplishments draw the attention of newspaper,
television stations, or other media who visit our schools to photograph, videotape,
and/or interview students and staff during various activities. In addition, we often
use pictures of our students in Berryessa Union School District’s publications and
the district’s website. For your child’s privacy, we must know whether or not you
want your child to be photographed, videotaped, or interviewed by the news media,
or for the district’s publications.
Please check appropriate box:
I DO GIVE PERMISSION for my child to be photographed, videotaped, or
interviewed by the news media for any reason and for the Berryessa Union
School District to use my child’s photograph or words in district publications.
I DO NOT GIVE PERMISSION for my child to be photographed,
videotaped, or interviewed by the news media for any reason. Nor do I give
my permission for the Berryessa Union School District to use my child’s
photograph or words in district publications. Note: I understand this media
release refusal does not apply to classroom displays or yearbooks.
Printed Student Name: ________________________________________________
Parent/Guardian Signature: ___________________________ Date: __________
Grade: _______ Birthdate: ____________Name of School: ________________
Student Id: ________________
PLEASE COMPLETE OTHER SIDE
Revised 10-22-18
E6163.4(a)
STUDENT USE OF TECHNOLOGY
ACCEPTABLE USE AGREEMENT
AND RELEASE OF DISTRICT FROM LIABILITY (STUDENTS)
The Berryessa Union School District authorizes students to use technology owned or otherwise
provided by the district as necessary for instructional purposes. The use of district technology is a
privilege permitted at the district's discretion and is subject to the conditions and restrictions set
forth in applicable Board policies, administrative regulations, and this Acceptable Use Agreement.
The district reserves the right to suspend access at any time, without notice, for any reason.
The district expects all students to use technology responsibly in order to avoid potential problems
and liability. The district may place reasonable restrictions on the sites, material, and/or information
that students may access through the system.
Each student who is authorized to use district technology and his/her parent/guardian shall sign this
Acceptable Use Agreement as an indication that they have read and understand the agreement.
Definitions
District technology includes, but is not limited to, computers, the district's computer network
including servers and wireless computer networking technology (wi-fi), the Internet, email, USB
drives, wireless access points (routers), tablet computers, smartphones and smart devices,
telephones, cellular telephones, personal digital assistants, pagers, MP3 players, wearable
technology, any wireless communication device including emergency radios, and/or future
technological innovations, whether accessed on or off site or through district- owned or personally
owned equipment or devices.
Student Obligations and Responsibilities
Students are expected to use district technology safely, responsibly, and for educational purposes
only. The student in whose name district technology is issued is responsible for its proper use at all
times. Students shall not share their assigned online services account information, passwords, or
other information used for identification and authorization purposes, and shall use the system only
under the account to which they have been assigned.
Students are prohibited from using district technology for improper purposes, including, but not
limited to, use of district technology to:
1.
Access, post, display, or otherwise use material that is discriminatory, libelous, defamatory,
obscene, sexually explicit, or disruptive
2.
Bully, harass, intimidate, or threaten other students, staff, or other individuals ("cyberbullying")
3.
Disclose, use, or disseminate personal identification information (such as name, address,
telephone number, Social Security number, or other personal information) of another student,
staff member, or other person with the intent to threaten, intimidate, harass, or ridicule that
person
4.
Infringe on copyright, license, trademark, patent, or other intellectual property rights
Revised 10-22-18
STUDENT USE OF TECHNOLOGY (continued) E6163.4(c)
5.
Intentionally disrupt or harm district technology or other district operations (such as destroying
district equipment, placing a virus on district computers, adding or removing a computer
program without permission from a teacher or other district personnel, changing settings on
shared computers)
6.
Install unauthorized software
7.
"Hack" into the system to manipulate data of the district or other users
8.
Engage in or promote any practice that is unethical or violates any law or Board policy,
administrative regulation, or district practice
Privacy
Since the use of district technology is intended for educational purposes, students shall not have any
expectation of privacy in any use of district technology.
The district reserves the right to monitor and record all use of district technology, including, but not
limited to, access to the Internet or social media, communications sent or received from district
technology, or other uses. Such monitoring/recording may occur at any time without prior notice for
any legal purposes including, but not limited to, record retention and distribution and/or
investigation of improper, illegal, or prohibited activity. Students should be aware that, in most
instances, their use of district technology (such as web searches and emails) cannot be erased or
deleted.
All passwords created for or used on any district technology are the sole property of the district. The
creation or use of a password by a student on district technology does not create a reasonable
expectation of privacy.
Personally Owned Devices
If a student uses a personally owned device to access district technology, he/she shall abide by all
applicable Board policies, administrative regulations, and this Acceptable Use Agreement. Any
such use of a personally owned device may subject the contents of the device and any
communications sent or received on the device to disclosure pursuant to a lawful subpoena or public
records request.
Reporting
If a student becomes aware of any security problem (such as any compromise of the confidentiality
of any login or account information) or misuse of district technology, he/she shall immediately
report such information to the teacher or other district personnel.
Consequences for Violation
Violations of the law, Board policy, or this agreement may result in revocation of a student's access
to district technology and/or discipline, up to and including suspension or expulsion. In addition,
violations of the law, Board policy, or this agreement may be reported to law enforcement agencies
as appropriate.
Revised 10-22-18
STUDENT USE OF TECHNOLOGY (continued) E6163.4(c)
Student Acknowledgment
I have received, read, understand, and agree to abide by this Acceptable Use Agreement and other
applicable laws and district policies and regulations governing the use of district technology. I
understand that there is no expectation of privacy when using district technology. I further
understand that any violation may result in loss of user privileges, disciplinary action, and/or
appropriate legal action.
Student Name: __
(Please print)
Grade: ______
School: ______________________________
Signature: ____________________________ Date:
Parent or Legal Guardian Acknowledgment
If the student is under 18 years of age, a parent/guardian must also read and sign the agreement.
As the parent/guardian of the above-named student, I have read, understand, and agree that my child
shall comply with the terms of the Acceptable Use Agreement. By signing this Agreement, I give
permission for my child to use district technology and/or to access the school's computer network
and the Internet. I understand that, despite the district's best efforts, it is impossible for the school to
restrict access to all offensive and controversial materials. I agree to release from liability,
indemnify, and hold harmless the school, district, and district personnel against all claims, damages,
and costs that may result from my child's use of district technology or the failure of any technology
protection measures used by the district. Further, I accept full responsibility for supervision of my
child's use of his/her access account if and when such access is not in the school setting.
Name: _____________________________________
(Please print)
Signature: _________________________ Date: __________
**** Should you wish to opt your child out of this technology agreement, it will be necessary
for the parent or guardian to meet with the site principal for further clarification and
discussion on how this choice would impact your child’s access to the curriculum.
California Department of Education
March 2008
Page 1 of 1
Oral Health Assessment Form
California law (Education Code Section 49452.8) states your child must have a dental check-up by May 31 of his/her first
year in public school. A California licensed dental professional operating within his scope of practice must perform the
check-up and fill out Section 2 of this form. If your child had a dental check-up in the 12 months before he/she started
school, ask your dentist to fill out Section 2. If you are unable to get a dental check-up for your child, fill out Section 3.
Section 1: Child’s Information (Filled out by parent or guardian)
Child’s First Name:
Last Name:
Middle Initial:
Child’s birth date:
Address:
Apt.:
City:
ZIP code:
School Name:
Teacher:
Grade:
Child’s Sex:
□ Male □ Female
Parent/Guardian Name:
Child’s race/ethnicity:
□ White □ Black/African American □ Hispanic/Latino □ Asian
□ Native American □ Multi-racial □ Other___________
□ Native Hawaiian/Pacific Islander □ Unknown
Section 2: Oral Health Data Collection (Filled out by a California licensed dental professional)
IMPORTANT NOTE: Consider each box separately. Mark each box.
Assessment
Date:
Caries Experience
(Visible decay and/or
fillings present)
□ Yes □ No
Visible Decay
Present:
□ Yes □ No
Treatment Urgency:
□ No obvious problem found
□ Early dental care recommended (caries without pain or infection;
or child would benefit from sealants or further evaluation)
□ Urgent care needed (pain, infection, swelling or soft tissue lesions)
Licensed Dental Professional Signature CA License Number Date
Section 3: Waiver of Oral Health Assessment Requirement
To be filled out by parent or guardian asking to be excused from this requirement
Please excuse my child from the dental check-up because: (Check the box that best describes the reason)
□ I am unable to find a dental office that will take my child’s dental insurance plan.
My child’s dental insurance plan is:
□ Medi-Cal/Denti-Cal □ Healthy Families □ Healthy Kids □ Other ___________________ □ None
□ I cannot afford a dental check-up for my child.
□ I do not want my child to receive a dental check-up.
Optional: other reasons my child could not get a dental check-up:
If asking to be excused from this requirement: ____________________________________________________
Signature of parent or guardian Date
Return this form to the school no later than May 31 of your child’s first school year.
Original to be kept in child’s school record.
The law states schools must keep student health information private. Your child's name will not be part of any report as a
result of this law. This information may only be used for purposes related to your child's health. If you have questions,
please call your school.
Information on the Oral Health Assessment/Waiver Request Form
To make sure your child is ready for school, California law, Education Code Section 49452.8, now requires that
your child have an oral health assessment (dental check-up) by May 31 in either kindergarten or first grade,
whichever is his or her first year in public school. Assessments that have happened within the 12 months before
your child enters school also meet this requirement. The law specifies that the assessment must be done by a
licensed dentist or other licensed or registered dental health professional.
Take the attached Oral Health Assessment/Waiver Request form to the dental office, as it will be needed for
your child’s check-up. If you cannot take your child for this required assessment, please indicate the reason for
this in Section 3 of the form. You can get more copies of the necessary form at your child’s school or online
from the California Department of Education’s Web site at http://www.cde.ca.gov/ls/he/hn/. California law
requires schools to maintain the privacy of students’ health information. Your child’s identity will not be
associated with any report produced as a result of this requirement.
The following resources will help you find a dentist and complete this requirement for your child:
1. Medi-Cal/Denti-Cal’s toll-free number or Web site can help you to find a dentist who takes Denti-Cal: 1-
800-322-6384; http://www.denti-cal.ca.gov. For help enrolling your child in Medi-Cal/Denti-Cal, contact
your local social service agency at (fill in appropriate local contact information, available at
http://www.dhs.ca.gov/mcs/medi-Calhome/CountyListing1.htm.)
2. Healthy Families’ toll-free number or Web site can help you to find a dentist who takes Healthy Families
insurance or to find out if your child can enroll in the program: 1-800-880-5305 or
http://www.healthyfamilies.ca.gov/hfhome.asp.
3. For additional resources that may be helpful, contact the local public health department at (fill in
appropriate local contact information, available at http://www.dhs.ca.gov/mcs/medi-
Calhome/CountyListing1.htm)
Remember, your child is not healthy and ready for school if he or she has poor dental health. Here is important
advice to help your child stay healthy:
Take your child to the dentist twice a year.
Choose healthy foods for the entire family. Fresh foods are usually the healthiest foods.
Brush teeth at least twice a day with toothpaste that contains fluoride.
Limit candy and sweet drinks, such as punch or soda. Sweet drinks and candy contain a lot of sugar, which
causes cavities and replaces important nutrients in your child’s diet. Sweet drinks and candy also contribute
to weight problems, which may lead to other diseases, such as diabetes. The less candy and sweet drinks,
the better!
Baby teeth are very important. They are not just teeth that will fall out. Children need their teeth to eat properly,
talk, smile, and feel good about themselves. Children with cavities may have difficulty eating, stop smiling, and
have problems paying attention and learning at school. Tooth decay is an infection that does not heal and can be
painful if left without treatment. If cavities are not treated, children can become sick enough to require
emergency room treatment, and their adult teeth may be permanently damaged.
Many things influence a child’s progress and success in school, including health. Children must be healthy to
learn, and children with cavities are not healthy. Cavities are preventable, but they affect more children than any
other chronic disease.
CALIFORNIA DEPARTMENT OF EDUCATION CHILD NUTRITION PROGRAMS
NUTRITION SERVICES DIVISION CNP-925
MEDICAL STATEMENT TO REQUEST
SPECIAL MEALS AND/OR ACCOMMODATIONS
1. SCHOOL/AGENCY
2. SITE
3. SITE TELEPHONE NUMBER
4. NAME OF PARTICIPANT
5. AGE OR DATE OF BIRTH
6. NAME OF PARENT OR GUARDIAN
7. TELEPHONE NUMBER
8. CHECK ONE:
Participant has a disability or a medical condition and requires a special meal or accommodation. (Refer to
definitions on reverse side of this form.) Schools and agencies participating in federal nutrition programs
must comply with requests for special meals and any adaptive equipment. A licensed physician must sign
this form.
Participant does not have a disability, but is requesting a special meal or accommodation due to food
intolerance(s) or other medical reasons. Food preferences are not an appropriate use of this form. Schools
and agencies participating in federal nutrition programs are encouraged to accommodate reasonable
requests. A licensed physician, physician’s assistant, or registered nurse must sign this form.
9. DISABILITY OR MEDICAL CONDITION REQUIRING A SPECIAL MEAL OR ACCOMMODATION:
10. IF PARTICIPANT HAS A DISABILITY, PROVIDE A BRIEF DESCRIPTION OF PARTICIPANT’S MAJOR LIFE ACTIVITY AFFECTED BY THE DISABILITY:
11. DIET PRESCRIPTION AND/OR ACCOMMODATION: (PLEASE DESCRIBE IN DETAIL TO ENSURE PROPER IMPLEMENTATION)
12. INDICATE TEXTURE:
Regular Chopped Ground Pureed
13. FOODS TO BE OMITTED AND SUBSTITUTIONS: (PLEASE LIST SPECIFIC FOODS TO BE OMITTED AND SUGGESTED SUBSTITUTIONS. YOU MAY ATTACH
A SHEET WITH ADDITIONAL INFORMATION)
A. Foods To Be Omitted B. Suggested Substitutions
14. ADAPTIVE EQUIPMENT:
15. SIGNATURE OF PREPARER*
16. PRINTED NAME
17. TELEPHONE NUMBER
18. DATE
19. SIGNATURE OF MEDICAL AUTHORITY*
20. PRINTED NAME
21. TELEPHONE NUMBER
22. DATE
* Physician’s signature is required for participants with a disability. For participants without a disability, a licensed physician,
physician’s assistant, or registered nurse must sign the form.
The information on this form should be updated to reflect the current medical and/or nutritional needs of the participant.
In accordance with Federal law and U.S. Department of Agriculture policy, this agency is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a
complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, DC 20250-9410, or call
(202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.
Please return to:
Child Nutrition Services Department
951 Piedmont Road
San Jose, CA 95132
CALIFORNIA DEPARTMENT OF EDUCATION CHILD NUTRITION PROGRAMS
NUTRITION SERVICES DIVISION CNP-925 PAGE 2
MEDICAL STATEMENT TO REQUEST
SPECIAL MEALS AND/OR ACCOMMODATIONS
INSTRUCTIONS
1. School/Agency: Print the name of the school or agency that is providing the form to the parent.
2. Site: Print the name of the site where meals will be served (e.g., school site, child care center, community
center, etc.)
3. Site Telephone Number: Print the telephone number of site where meal will be served. See #2.
4. Name of Participant: Print the name of the child or adult participant to whom the information pertains.
5. Age of Participant: Print the age of the participant. For infants, please use Date of Birth.
6. Name of Parent or Guardian: Print the name of the person requesting the participant’s medical statement.
7. Telephone Number: Print the telephone number of parent or guardian.
8. Check One: Check () a box to indicate whether participant has a disability or does not have a disability.
9. Disability or Medical Condition Requiring a Special Meal or Accommodation: Describe the medical
condition that requires a special meal or accommodation (e.g., juvenile diabetes, allergy to peanuts, etc.)
10. If Participant has a Disability, Provide a Brief Description of Participant’s Major Life Activity Affected
by the Disability: Describe how physical or medical condition affects disability. For example: ”Allergy to
peanuts causes a life-threatening reaction.”
11. Diet Prescription and/or Accommodation: Describe a specific diet or accommodation that has been
prescribed by a physician, or describe diet modification requested for a non-disabling condition. For example:
”All foods must be either in liquid or pureed form. Participant cannot consume any solid foods.”
12. Indicate Texture: Check () a box to indicate the type of texture of food that is required. If the participant
does not need any modification, check “Regular”.
13. A. Foods to Be Omitted: List specific foods that must be omitted. For example, the “exclude fluid milk.”
B. Suggested Substitutions: List specific foods to include in the diet. For example, “calcium fortified juice.”
14. Adaptive Equipment: Describe specific equipment required to assist the participant with dining. (Examples
may include a sippy cup, a large handled spoon, wheel-chair accessible furniture, etc.)
15 Signature of Preparer: Signature of person completing form.
16. Printed Name: Print name of person completing form.
17. Telephone Number: Telephone number of person completing form.
18. Date: Date preparer signed form.
19. Signature of Medical Authority: Signature of medical authority requesting the special meal or
accommodation.
20. Printed Name: Print name of medical authority.
21. Telephone Number: Telephone number of medical authority.
22. Date: Date medical authority signed form.
DEFINITIONS*:
“A Person with a Disability” is defined as any person who has a physical or mental impairment which substantially limits one or more major
life activities, has a record of such impairment, or is regarded as having such an impairment.
“Physical or mental impairment” means (a) any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one
or more of the following body systems: neurological; musculoskeletal; special sense organs; respiratory, including speech organs;
cardiovascular; reproductive, digestive, genito-urinary; hemic and lymphatic; skin; and endocrine; or (b) any mental or psychological disorder,
such as mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities.
“Major life activities” are functions such as caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, breathing,
learning, and working.
“Has a record of such an impairment” is defined as having a history of, or have been classified (or misclassified) as having a mental or
physical impairment that substantially limits one or more major life activities.
(*Citations from Section 504 of the Rehabilitation Act of 1973)
Child’s Name: ________________________ Birthdate: _______________ Male/Female School: ____________________
Last, First month/day/year
Address________________________________________________________ Phone: ______________ Grade: __________
Street City Zip
SCC TB Risk Assessment Form_Revised 3-18-2019 1
Santa Clara County Public Health Department
Tuberculosis (TB) Risk Assessment for School Entry
This form must be completed by a U.S. licensed primary care provider and returned to the child’s school.
1. Was your child born in, or has your child resided in or traveled to (for more than
one week) a country with an elevated TB rate?*
Yes No
2. Has your child been exposed to anyone with TB disease?
Yes No
3. Has a family member had a positive TB test or received medications for TB?
Yes No
4. Was a parent, household member, or visitor who stayed in the child’s home for
>1 week, born in a country with an elevated TB rate?*
Yes No
5. Is your child immunosuppressed [e.g. due to HIV infection, organ transplant,
treatment with TNF-alpha inhibitor or high-dose systemic steroids (e.g. prednisone
≥ 15 mg/day for ≥ 2 weeks)].
Yes No
*Most countries other than the U.S., Canada, Australia, New Zealand, or a country in western or northern Europe. This
does not include tourist travel for <1 month (i.e. travel that does not involve visiting family or friends, or involve
significant contact with the local population).
If YES, to any of the above questions, the child has an increased risk of TB and should have a TB blood test (IGRA,
i.e. QuantiFERON or T-SPOT.TB) or a tuberculin skin test (TST) unless there is either 1) a documented prior positive
IGRA or TST performed in the U.S. or 2) no new risk factors since last documented negative IGRA (performed at age
≥2 years in the U.S.) or TST (performed at age ≥6 months in the U.S.).
All children with a current or prior positive IGRA/TST result must have a medical evaluation, including a chest
x-ray (CXR; posterior-anterior and lateral for children <5 years old is recommended). CXR is not required for
children with documented prior treatment for TB disease, documented prior treatment for latent TB infection,
or BCG-vaccinated children who have a positive TST and negative IGRA. If there are no symptoms or signs of
TB disease and the CXR is normal, the child should be treated for latent TB infection (LTBI) to prevent
progression to TB disease.
Enter test results for all children with a positive risk assessment:
Interferon Gamma Release Assay (IGRA)
Date:
Result: Negative Positive Indeterminate
Tuberculin Skin Test (TST/Mantoux/PPD)
Date placed: Date read:
Induration _____ mm
Result: Negative Positive
Chest X-Ray Date:__________ Impression: Normal Abnormal
LTBI Treatment Start Date: __________
Rifampin daily - 4 months
Isoniazid/rifapentine - weekly X 12 weeks
Isoniazid daily - 9 months
Other:__________________
Prior TB/LTBI treatment (Rx & duration):
____________________________________
Treatment medically contraindicated:
____________________________________
Declined against medical advice
Please check one of the boxes below and sign:
Child has no TB symptoms, no risk factors for TB, and does not require a TB test.
Child has a risk factor, has been evaluated for TB and is free of active TB disease.
Child has no new risk factors since last negative IGRA/TST and no TB symptoms.
____________________________________________ ___________
Health Care Provider Signature, Title Date
Name/Title of Health Provider:
Facility/Address:
Phone number:
County of Santa Clara
Public Health Department
Tuberculosis Prevention & Control Program
976 Lenzen Avenue, Suite 1700
San José, CA 95126
408.885.2440
SCC TB Risk Assessment Form_Revised 3-18-2019 2
Testing Methods
An Interferon Gamma Release Assay (IGRA, i.e. QuantiFERON or T-SPOT.TB) or Mantoux tuberculin skin test (TST)
should be used to test those at increased risk. An IGRA can be used in all children ≥ 2 years old and is preferred in
BCG-vaccinated children to avoid a false positive TST result. A TST of ≥10mm induration is considered positive. If a
child has had contact with someone with active TB disease (yes to question 2 on reverse), or the child is
immunosuppressed, then TST ≥5 mm is considered positive. If a BCG-vaccinated child has a positive TST, and an
IGRA is subsequently performed and is negative, testing is considered negative unless the child was exposed to
someone with TB disease or is immunosuppressed. For immunosuppressed children, screening should be performed
by CXR in addition to a TST/IGRA (consider doing both) and symptom review.
Evaluation of Children with Positive TB Tests
All children with a positive IGRA/TST result must have a medical evaluation, including a CXR (posterior-
anterior and lateral is recommended for children <5 years old). A CXR is not required for a positive TST with
negative IGRA in a BCG-vaccinated child, or if the child has documentation of prior treatment for TB disease
or treatment for latent TB infection.
For children with TB symptoms (e.g. cough for >2-3 weeks, shortness of breath, hemoptysis, fever, weight
loss, night sweats) or an abnormal CXR consistent with active TB disease, report to the County of Santa Clara
Public Health Department TB Program within one day. The child will need to be evaluated for TB disease with
sputum AFB smears/cultures and nucleic acid amplification testing. A negative TST or IGRA does not rule out
active TB disease in a patient with symptoms or signs of TB disease. The child cannot enter school unless
active TB disease has been excluded or treatment has been initiated.
If there are no symptoms or signs of TB disease and the CXR is normal, the child should be treated for latent
TB infection (LTBI). Do not treat for LTBI until active TB disease has been excluded.
Short-course regimens (rifampin daily for four months or 12-dose weekly isoniazid/rifapentine) are preferred
(except in persons for whom there is a contraindication, such as a drug interaction or contact to a person with
drug-resistant TB) due to similar efficacy and higher treatment completion rates as compared with 9 months of
daily isoniazid
Treatment Regimens for Latent TB Infection
Rifampin 15 - 20 mg/kg (max. 600 mg) daily for 4 months
12-dose Weekly Isoniazid/Rifapentine (3HP) Regimen:
Isoniazid
2-11 years old: 25 mg/kg rounded up to nearest 50 or 100 mg (max. 900 mg)
≥ 12 years old: 15 mg/kg rounded up to nearest 50 or 100 mg (max. 900 mg)
Rifapentine
10.0-14.0 kg: 300 mg
14.1-25.0 kg: 450 mg
25.1-32.0 kg: 600 mg
32.1-50.0 kg: 750 mg
>50 kg: 900 mg
Vitamin B6 50 mg weekly
Isoniazid 10 mg/kg (range, 10-15 mg/kg; max. 300 mg) daily for 9 months. Recommended pyridoxine dosage is
25 mg for school-aged children (or 1-2 mg/kg/day).
For additional information: www.sccphd.org/tb or contact the TB Control Program at (408) 885-2440.
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RESIDENCY DECLARATION (Berryessa Union School District)

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Completed 19 August 2020

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