Fillable Rancho Starbuck Documentation Checklist

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Rancho Starbuck Documentation Checklist

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Rancho Starbuck
Documentation Checklist
For students BRAND NEW to the Lowell Joint School District
LJSD Student Information Form
Student Health Survey
Home Language Survey
Parent/Guardian Residency Verification Form
Military Connected Family Form
McKinney-Vento Assistance Act Form
Copy of UP TO DATE immunization history. All students entering 7
th
grade will need to provide proof of receiving the Tdap booster shot prior
to starting school.
Proof of residency (Current utility bill, rent/mortgage bill or escrow
papers. NOT required for students who have only ever attended private
school.) If residing with another family, there is an additional form that
needs to be completed. Please call our office to obtain the form.
Inter-District Attendance Permit (Required only for students coming
from private school)
Elective Card
Student is NOT enrolled until ALL required documentation is received
Email all documents to tserrano@ljsd.org
LOWELL JOINT SCHOOL DISTRICT
PLEASE PRINT STUDENT INFORMATION FORM COMPLETE ALL SECTIONS
Pupil’s Entering Current
Name: Grade: Date:
Last First Middle ( )
Primary Phone Number
Street Address City Zip County Parent/Guardian E-mail Address
Birth Date: Male Female
Month Day Year
School Last Attended: Last Day of Attendance:
Name
School Address: ( ) ( )
Street Address City State Phone Number Fax Number
FAMILY INFORMATION
Who has legal custody of this pupil? Father Mother Foster ID # Other
Please specify
( )
Father/Guardian Address (If different from above) City Cell or Home Phone #
( )
Father’s Employer Address City
Cell or Home Phone #
( )
Mother/Guardian Address (If different from above) City
Cell or Home Phone #
(
)
Mother’s Employer Address City
Cell or Ho
me Phone #
Other Adult Living In the Home:
Name Relationship
Other Children Living in the Home:
Name
Relationship
Date of Birth
Name
Relationship
Date of Birth
Parent Education Level (Please circle highest grade level completed) Required by the Public Schools Accountability Act, Education Code Section 60630:
Father: High School Not a High Some College
Graduate School Graduate College Graduate
Graduate School Decline to State
Mother: High School Not a High Some College
Graduate School Graduate College Graduate
Graduate School Decline to State
Was your child enrolled in a special program? Yes No
Type of services and/or program (please check): Special Education (IEP) ELD Gifted and Talented
Speech/Language Therapy 504 Plan Other type of program not listed:
Has your child ever attended school in Lowell Joint School District? Yes No
If yes, name of school: Grade(s) attended
Did your child attend pre-school? Yes No If yes, name of pre-school:
FOR OFFICE USE ONLY
Grid: Teacher: Enrollment Date: Address Verified:
Permanent Records Requested: Permanent Records Received: Birth Date Verified By:
Immunization Status:
Ethnic Identity: Is this student Hispanic or Latino? (Select only one) No, not Hispanic or Latino Yes, Hispanic or Latino (Required by CA Gov Code Sec. 8310.5)
No matter what you selected above, please continue to answer the following by marking one or more boxes to indicate what you consider your race to be.
American Indian/Alaska Native Cambodian Guamanian Japanese Other Asian Tahitian
Asian Indian Chinese Hawaiian Korean Other Pacific Islander Vietnamese
Black or African American
Filipino
Hmong
Laotian
Samoan
White
Parent/Guardian Signature Date
Student Information form: Revised 3/19(RV)
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LOWELL JOINT SCHOOL DISTRICT
STUDENT HEALTH SURVEY
School Year: _______________
Name: ________________________________ Male Female Date of Birth: _________________
School: ___________________________ Grade: _________________ Teacher: _____________________
Physician: _____________________________ Physician Phone#: __________________________________
Health Insurance Plan: Private _________________________Medi-Cal ____________ None ______________
PLEASE CHECK ALL THAT APPLY
NONE
Comments
: __________________________________________
___________________________________________
_________
___________________________________________
_________
PAST MEDICAL HISTORY
Premature Birth (35 weeks or earlier)
Diabetes
Seizures/Epilepsy
Heart Defect/Heart D
isease
Hearing Problems
Frequent Ear Infections
Frequent Headaches
ADD/ADHD
Wears Glasses
Other
ALLERGIES NONE
Allergic to Bee/Wasp Stings
Food Allergies:
Peanuts Milk Other ________________________________________________________
Environmental Allergies:
Latex Hay fever
Type of Allergic Reaction:
Household Animals Dust Grass Pollen Mold
Local Reaction – Pain, itching, minimal swelling
and redness at site of contact
Systemic Reaction – Difficulty breathing, flushing of skin, rash, faintness
Requires Epinephrine Pen at School? Yes No
Medication to treat Allergies (list Medicines) _________________________________________________
NONE
Exercise
Seasonal Other __________________________________
ASTHMA
Triggered by: Sickness
Requires Medication:
Daily As Needed Only With Exercise
Medications Required At School: Inhaler Nebulizer Other
__________________________
ADDITIONAL MEDICAL INFORMATION NONE
Surgeries/Hospitalization _________________________________________________________________
__________________
_______________________________________________
___________________
______________________________________________
Illness
Physical Handicaps
Other
__________________
_______________________________________________
CURRENT DAILY MEDICATIONS NONE
WILL MEDICATIONS BE GIVEN AT SCHOOL
1. _______________________________________
2. ___________________
____________________
3. ___________________
____________________
4 ._____________
__________________________
Yes N o
Yes N o
Yes N o
Yes N o
Please remember that ALL medications, including inhalers or over the counter substances have 3 requirements in order to be
given at school. 1). Parent permission AND 2).Physician order AND 3). Matching pharmacy label on bottle.
Children are NOT permitted to carry ANY medication at school without permission from doctor AND school nurse.
___________________________________________
_____________ __________________
Parent Signature Date
Health Services updated 10/24/12/sj
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Date Lowell Joint School District School
HOME LANGUAGE SURVEY
Teacher
The California Education Code requires schools to determine the language(s) spoken at home by each
student. This information is essential in order to schools to provide meaningful instruction for all students.
Your cooperation in helping us meet this important requirement is requested. Please answer the following
questions and have your son/daughter return this form to his/her teacher. Thank you for your help.
Name of student:
Last First Middle Grade Age
1. Which language did your son or daughter learn when he or she first began to talk?
2. What language does your son or daughter most frequently use at home?
3. What language do you use most frequently to speak to your son or daughter?
4. Name the language most often spoken by the adults at home:
5. Birthplace: City, State, Country
6. Please list:
Date entered U.S.
Date first attended U.S. school
Date first attended C.A. school
Rev. 4/06 Signature of Parent or Guardian
If a language other than English appears on lines 1, 2, 3 or on all of the first three, the student must be assessed within 30 days
of initial enrollment in English comprehension, speaking, reading, and writing.
(EC 306(a); EC 62002, former EC 52164.1(b); (c); 5 CCR 4304, 4305; 34 CFR 300.300.300.532(s)(c).)
(Over for Spanish version)
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Lowell Joint School District
PARENT/GUARDIAN RESIDENCY VERIFICATION
State law provides that public school districts are to serve only those students who are
residents in the District or students who have an approved Inter-district Permit.
Ownership of real property within the District does not in and of itself constitute
residency. The Lowell Joint School District routinely investigates addresses to verify
their validity.
DECLARATION OF RESIDENCY
Parent/Guardian ResidencyVerification.doc
February, 2007
I hereby certify that the address as given for enrollment purposes is true and correct.
I understand and agree that if it is determined that this information is false, I am in
violation of State law. I further understand that if it is determined that a registered
student is not a resident of the Lowell Joint School District and does not have a valid
Interdistrict Permit allowing attendance, the student shall be removed from the
District immediately and will be denied all services by the District.
I agree to notify the school immediately upon any change of address.
I certify under penalty of perjury under the laws of the State of California that the
foregoing is true and correct.
Date: _______________
Print Student’s Name: _________________________________________________
Print Student’s Address: _______________________________________________
Address City Zip
Print Parent’s/Guardian’s Name: _________________________________________
Parent’s/Guardian’s Signature: __________________________________________
Military Connected Family
In efforts to help address the needs and/or concerns of Military Connected Families,
especially during the deployment period, please complete the following section below.
Date:
School:
Student’s Name
(Last Name) (First Name)
Grade Level Student’s Date of Birth
(0RQWK'D\Year)
Parent/Guardian Name
(Last Name) (First Name)
Address________________________________________________________________
(Street) (City) (Zip Code)
Telephone Number ( )
Is Mother, Father, or Legal Guardian currently serving in the Military, including
Active Duty, Guard, Reserve or Veteran?
Check One: Yes No
If Yes, which parent or guardian?
If Yes, which Military Branch?
If Yes, which status:
ACTIVE DUTY (full time) YES
GUARD YES
RESERVE YES
VETERAN YES
Lowell Joint School District
McKinney-Ve
nto Assistance Act
Confidential Form
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
This form assists school personnel in complying with the legal guidelines for school enrollment for
children who meet the eligibility criteria for services provided under the McKinney-Vento Assistance Act
(Title X, Part C of the No Child Left Behind Act).
PLEASE PRINT
Date
School
Student’s Name Grade
(Last Name) (First Name)
Student’s Date of Birth
(Month) (Day)
Parent/Guardian Name
(Last Name)
(Year)
Unaccompanied Youth Y N
(First Name)
Address
Telephone Number ( )
PL
EASE CHECK THE FOLLOWING LIVING SITUATION THAT APPLIES TO THE STUDENT:
___________ Living in home, rented home, or apartment (one family)
___________ Due to economic hardship, loss of housing, or similar reason, living with friends or
relatives. Please explain:
___________ Living in a shelter
___________ Living in a hotel or motel
___________ Living in a campground, park, or car
___________ Awaiting foster care placement
___________ Living in other circumstances Please explain:
Parent Signature: Date:
FOR DISTRICT OFFICE USE ONLY:
Administrator Signature: Date:
Send a copy to Educational Services if requesting evaluation for eligibility under McKinney-Vento
Assistance Act.
INTER-DISTRICT ATTENDANCE PERMIT
Student’s Last Name: __________________ Student’s First Name: ____________________
Students who reside outside the attendance boundaries must adhere to the below guidelines. I understand that
students outside the attendance boundaries must meet the expectations of Rancho-Starbuck in the areas of
grades, behavior and attendance to remain part of the Rancho-Starbuck student body.
Permit may be withdrawn for any of the following reasons:
GRADES: A student must maintain a C average and satisfactory citizenship.
ATTENDANCE: Chronic absences or excessive tardies will result in loss of transfer.
BEHAVIOR: Must abide by appropriate school behavior guidelines. School suspension may result in
immediate loss of transfer.
RESIDENCE: Current residence must be on file in our office.
I certify that all information provided in registration materials is accurate and up to date. I further agree to the
permit criteria on this form.
___________________________________________________________________________________________
Signature of Parent/Guardian Date
_________________________________________________________________________________________________________________________________
Print Parent/Guardian Name Date
_________________________________________________________________________________________________________________________________
Signature of Student Date
_________________________________________________________________________________________________________________________________
Signature of Administrator Date
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Rancho Starbuck School
7th & 8th Grade Elective Card
Last Name First Name
Please make 4 choices from elective classes listed below. Mark in order of preference, #1, #2, #3, #4.
Every effort will be made to place you in your chosen electives based upon your entire schedule.
VISUAL & PERFORMING ARTS STEM CLASSES
(Science, Technology, Engineering,Math)
Instrumental Music++, 1 year Design & Construction, 1 semester (0813)
Choir++, 1 year (0703)
Robotics, 1 year (0814)
Beginning Drama, 1 semester (0705) Music Production, 1 semester (0811)
Advanced Drama++, 1 semester (0706) (8th grade ONLY)
Advanced Computer Science^, 1 year (0812)
Advanced Drama++, 1 year (0706 )(8th grade ONLY)
Drawing++, 1 semester (0601) ADDITIONAL
Painting++, 1 semester (0602) Sports Agility, 1 semester (0501)
Ceramics & 3-D Design++, 1 semester (0604)
Peer Tutor, 1 semester (0908) (8th grade ONLY)
Adv. Ceramics & 3-D Design*++, 1 semester (0605)
Intro to Spanish, 1 semester (0401) (8th grade ONLY)
Dance 1, 1 semester (0708)
Honors Academy & Cofa Academy are 8th grade only Programs Additional Electives Available:
^Course qualifies for Pre AP/IB Honors Academy
Dance Company (audition) and Journalism (application)
++ Course qualifies for Conservatory of Fine Arts (Cofa)
See enclosed flyer for details.
*Prerequisite: Ceramics & 3D Design
Elective choices will be adjusted accordingly.
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Rancho Starbuck Documentation Checklist

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Completed 16 April 2021

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