LOS ANGELES UNIFIED SCHOOL DISTRICT Early Childhood ...

LOS ANGELES UNIFIED SCHOOL DISTRICT Early Childhood Education

EEC ______________________________________ Phone: _____________ E-mail: _________________

This document should be included in the family file.

PARENT ENROLLMENT PACKET CHECKLIST

Child Name/s: ____________________________________________ Date of Birth: ____________________

Welcome to our Early Education Center. In order to enroll your child, please have available and completed by your appointment date, the documents & information checked below:

(LAUSD SECTION)

Received COMPLETE

Scanned to EESIS

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

Immunization records for child being enrolled (California Immunization Requirements for Child Care 01/19)

Proof of income ? One full month's worth of check stubs for the prior month for each parent employed. (If paid weekly, submit the last 4 consecutive check stubs, if paid bi-weekly, submit the last 2 consecutive check stubs.)

Verification of TANF or other cash assistance (copy of most recent check ? prior month, Notice of Action or Cash Issuance Receipt)

Verification of California Residency (CA ID, CA Driver's License, Current Utility Bill, Rent Receipt, Lease Agreement, etc.)

ATTACHMENTS

Home Language Survey Student Enrolment Form Ref 5259.1 08/19

Health History Card (white, to be completed by the parent/guardian) 07/86

Physical Exam ? Physician's Report (LIC 701 form to be completed by the doctor. Must be within the last 12 months and include screening of TB risk) 08/08

Verification of Employment and Salary ? Form 83.56 04/19

Self-Certification of Income (if applicable) 04/19

Verification of Training ? Form EESD 9605 01/15 (Progress Report at Recertification Time)

Request for study time must be written and provided by parent

Statement of Incapacity ? CD 9606 06/08 Child Protective Services Referral Form 83.66 06/19 Seeking Employment Agreement 04/18

Los Angeles Unified School District Parent Handbook ? Forms completed & signed SY 20-21

Student Emergency Information Form (At least 3 names, addresses and telephone numbers of persons, 18 years or older, authorized to pick up your child in case of emergency or illness) Make sure that the name matches what appears on Driver License or I.D.s 01/14

If Applicable: Verification of Other Care Providers ? Form 84.26 03/19

Student Housing Questionnaire 07/19; Migrant Education Program Questionnaire 10/18 & Safe Gun Storage Acknowledgement Form 09/19

Other : _________________________________________________________________

Your appointment date is _______________________________________ Time: _________ AM / PM

You must bring all requested documents on that date, and be ready to stay 30 minutes, so that we can verify the information and give you the policies and procedures of this program. If you do not show up to your appointment, we will proceed to enroll the next family on our waiting list.

This document should be included in the family file.

LOS ANGELES UNIFIED SCHOOL DISTRICT Early Childhood Education

EEC ______________________________________ Phone: _____________ E-mail: _________________

This document should be included in the family file.

FOR LAUSD USE ONLY

CASE NOTES

FOR LAUSD USE ONLY

EESIS ID# _____________ Parent/s Name________________________ Room # ________

Child Name ________________________ Birthday ____________ Program CCTR CSPP

Has the family previously been enrolled in a LAUSD ECED Program?

YES NO

CONTRACT SIGNATURES

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

COMPLETE

SCANNED TO EESIS

CD 9600 page 1 & 2 ? with proper box checked, dated, initialed (Single Parent) and Signed by Parent and Principal

____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________

This document should be included in the family file.

LOS ANGELES UNIFIED SCHOOL DISTRICT

REFERENCE GUIDE

STUDENT ENROLLMENT FORM

Attachment A

Student Name:

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

C. HOME LANGUAGE AND ETHNICITY INFORMATION

Home Language of the Student Which language did your child learn when he/she/they first began to talk?

Which language does your child most frequently use at home?

Which language do you (the parents or guardians) most frequently use when speaking to your child?

Which language is most often spoken by adults in the home? (parents, guardians, grandparents, or any other adults)

Has this student received any formal English language instruction? Yes No Student's Primary Ethnicity

Is the student's ethnicity Hispanic or Latino?

Yes No

Student's Primary Race (Check One)

African American or Black

American Indian or Alaska Native

White

Asian:

Asian Indian Cambodian Chinese Filipino Hmong Vietnamese Other Asian:

Pacific Islander:

Guamanian Native Hawaiian Samoan Other Pacific Islander:

Tahitian

Decline to State

Japanese Korean

Student's Additional Race (Optional)

African American or Black

Asian:

American Indian or Alaska Native

White

Asian Indian Cambodian Chinese Filipino Hmong Vietnamese Other Asian:

Pacific Islander:

Guamanian Native Hawaiian Samoan Other Pacific Islander:

Tahitian

Decline to State

Japanese Korean

Laotian Laotian

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

X Signature

Date

Printed Name

Relationship to Student

REF-5259.1 Student Health and Human Services

August 16, 2019

LOS ANGELES UNIFIED SCHOOL DISTRICT ? PERMANENT HEALTH HISTORY

Students Name _______________________________________ Sex: M ___ F___ Birth Date _________________

LAST

FIRST

MIDDLE

MONTH DAY YEAR

Last School or Children's Center Attended:_______________________________ Name

Location __________________________________________________________

Health Care Provider/Physician ______________________________ Date of late physical examination ____________________________

City & State

Family Dentist ____________________________________________

Present Grade ________ SPECIAL CLASS OR SCHOOL ___________________________________________

Date of last dental examination ______________________________ CHILD'S ILLNESS (past or present) please check ():

FAMILY: Father

Living with child(Names)

HEALTH

Chickenpox

Yes NO

Yes NO

Frequent sore throat

Mother

Stepparent Others

Meningitis

Mumps Rubella (3 day measles)

Ear aches/infections

Hearing loss Speech problem

Brothers Sisters

How Many Older How Many Younger

HEALTH

Has child ever been hospitalized overnight? Yes ___ No ___ Name of hospital _____________________City______________State_________ Dates in hospital ____________________________________________________ Reasons for hospitalization ___________________________________________ __________________________________________________________________ Is child on medication? Yes ____ No ____ Name of medicine __________________________________________________ Amount _____________________ Frequency ___________________________ Are physical activities limited? Yes ______ No______ If yes, reason for limitation: ___________________________________________

Rubeola (10-day measles)

Eye problem

Whooping Cough Positive TB Skin Test Bronchitis

Wears glasses/contacts Heart condition/murmur High Blood Pressure

Pneumonia Asthma

Hives or Eczema Drug or Other Allergy

Head Injury Seizures/Unconscious

Kidney Problem Diabetes

Blood disease Menstrual problem

Hernia Parasites(worms)

Other serious accidents or illness (describe) ______________________

BIRTH HISTORY MOTHER'S PREGNANCY:

Infections Bleeding High Blood Pressure Toxemia Diabetes Other Complications of Pregnancy 9-Month Pregnancy

Type of Delivery

Child's birth weight__________

YES NO

child's birth condition (check) good _______ poor ________ If poor, describe: ___________________________________________________ __________________________________________________________________

ILLNESS DURING FIRST 2 WEEKS OF LIFE:

YES NO

Trouble breathing Seizures

Cyanosis(blue color) Jaundice(yellow color) Feeding problems Anemia Birth defect

Required incubator Went home with mother

DEVELOPMENT HISTORY At what age did your child: Sit alone _________________ Stand alone ______________ Say words ________________ Toilet train _______________

Crawl _________________________ Walk _________________________ Use sentences _________________ Feed self ______________________

PLEASE CHECK ( ) DOES YOUR CHILD:

Enjoy learning Like school

YES NO Bite nails Suck thumb

YES NO

Like other children Eat well Drink milk Eat Breakfast

Sleep well Follow directions

Wet bed Seem shy Fall frequently Have temper tantrums Seem overactive

What time does your child go to bed? ___________________________ Do you have any questions or concerns about your child's health? Please list. _________________________________________________

_______ Date _______ Date

_______________________________________________ Parent/Guardian Signature

_______________________________________________ History taken by (Name)

_______________________________________________ Title

_______________________________________________ Name of School

FORM 34-EH-67 7/86 STK. NO. 815292 C.C.9661215292

LOS ANGELES UNFIED SCHOOL DISTRICT Student Health and Human Services Division

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