Kindergarten/Transitional Kindergarten Packet

Carrillo Elementary School
Transitional Kindergarten (TK) &
Kindergarten Registration
2014-2015
Welcome to Carrillo Elementary School! We are excited that your son or daughter will be a member of our
school family. Carrillo's Kindergarten program is designed to provide your child with educational experiences and
opportunities to ensure that they are challenged, motivated and successful.
TK and Kindergarten registration will begin on Thursday, February 6 th from 8:00 a.m. - 3:00 p.m. each day.
The deadline for completed Kindergarten packets for those families who would like to be included in the lottery
for morning Kindergarten is Thursday, April 24 th at 3:00 p,m. All SMUSD schools will continue to register students
after this date for the afternoon session or morning waiting list. The Kindergarten lottery will be held on Friday,
April 25th at 3:30 p.m. (check in at our front office for location of lottery). It is not mandatory to be present at
the lottery. Results of the lottery will be made available on the doors of the front office and on the Carrillo
website at 4:00 p.m. on Monday, April 28 th .
Registration
A complete registration packet will be required for all entering TK and Kindergarten students.
Kindergarten students must have a birthday on or before September 1, 2009 and TK students must have a
birthday betWeen September 2, 2009 and December 2, 2009 and to register. The following items ARE
MANDATORY for registration, we will NOT accept packits that do not have these items:
•
Birth Certificate (original and a copy)
•
A Completed Health Physical Form (CHOP form) or an Appointment Card for the physical
•
Immunization Records (original, we will make a copy)
A Current Dental/Oral Screening is required and the completed form presented
Verification of Residency (2 items), see registration packet for details
•
•
Office Hours
Our school office is open each day from 7:00 a.m, - 4:00 p.m. Please feel free to call us anytime if we can
be of assistance in preparation for the upcoming school year (760-290-2900).
A Tradition
Traditions must begin somewhere and at Carrillo we start our tradition of excellence in our Kindergarten program
with your child. Kindergarten is a time to prepare our students for success. The joys of learning and the positive
feeling of a job well done are essential building blocks in the foundation of a positive school experience. We look
forward to working with you to ensure that your child has a positive and productive experience at Carrillo
Elementary School.
Sincerely,
Fran Pistone
Principal
Betsy Kannenberg
Assistant Principal
SAN MARCOS
engaging
UN1FtED SCHOOL DISTRICT
students...inspiring 'futures
Kindergarten Lottery, 2014
The purpose of the San Marcos Unified School District's kindergarten lottery is to
establish a fair means of placing children into the morning kindergarten programs. Each
year many families express a need for the morning classes. All schools will conduct
lotteries for kindergarten session placement. We believe that this will make it more
convenient for all parents. Following is the schedule all schools will follow for
kindergarten registration this year:
Kindergarten packets will be available and registration begins at all
February 6 th
schools from 8:00 a.m. — 3:30 p.m. Packets will be available in the front office and can
also be printed from the www.carrilloelementary.org website.
-
—
April 24th by 3:00 p.m. is the deadline for completed kindergarten packets for those
families that would like to be included in the lottery for morning kindergarten.
***Schools will continue to register students after this date for afternoon session or
morning waiting list.
April 25 th —Kindergarten lottery at all schools — 3:30 p.m. check in with front office for
location of lottery. Attendance is welcOmed,.but not mandatory.
April 28th
Results of the lottery will be made available at 4:00 p.m. The lists of those
students who will be enrolled in the morning sessions will be on the front office doors
and on Carrillo's website.
—
***Many of our schools fill their kindergarten classes quickly. It is imperative that
parents enroll as soon as possible to ensure a spot for your child at your school.
If you have any questions about kindergarten registration or the session lottery, please
feel free to contact the school office. Thank you.
COLTS: Community of Learners Target Success
Registration Check-Off List
Required Forms for Kindergarten
1
Enrollment form
2
Student Emergency Information
3
Student Health History Information
4
School Entry Health Check Up form
5
Dental Assessment form
6
Kindergarten Questionnaire
7
State Certified Original Birth Certificate
8
Original Immunization Record
9
Residency Verification form AND 2 proofs of residency (see form for acceptible proofs)
(must be signed and dated by physician)
(must be signed and dated by dentist)
(a copy will be made and the original returned immediately)
SAN MARCOS
Birth Verif.
Res. Verif.
UNIFIED KHOO!. DISTRi.cr
engaging studords...irtspiring futures
Middle Name
Legal First Name
Legal Last Name
❑
Student ID #
School
Start Date
1:3 Female
Male
For Office Use Only
Att. CAT:
ELLRC Ref:
Birth Date
Birth Country
Birth State
Birth Place
Grade
As mandated by federal and state law, please answer the following questions to identify this student's ethnicity and race. This
information will only be used for reporting total counts of pupils, and will not be released in a personally-identifiable form.
Is this student's ethnicity Hispanic or Latino?
0 Yes
0 No
Please mark one or more of the following boxes to indicate the student's race.
O American Indian or Alaska Native
O Asian-Korean
Ci Asian-Laotian
O Asian-Other
O Pacific Islander
O Filipino
O Asian-Chinese
O Asian-Vietnamese
O Asian-Cambodian
O Pacific Islander-Hawaiian
0 Pacific Islander-Tahitian
CI African American
0 Asian-Japanese
CI Asian-Indian
O Asian-Hmong
C3 Pacific Islander-Guamanian
O Pacific Islander-Other
O White
Tract Code
Primary Address
Home Address (Street)
State
City
Zip Code
Home Language Survey
The California Education Code requires schools to determine the language(s) spoken at home by each student. This information is
essential in order for the school to provide adequate instructional programs and services.
1.
2.
3.
4.
Which language did your child learn when he or she first began to speak?
What language does your child most frequently use at home?
What language do you use most frequently to speak to your child?
Name the language spoken most often by the adults at home?
Residence Information
Please select the option that best describes your housing situation:
0 Duplex
0 Apartment/Condo
0 Single Family Dwelling
0 Mobile Home
O Campground
0 Auto/RV or RV Park
0 Hotel/Motel
0 Shelter
0 Other
C3 Foster Home
Are you temporarily sharing housing with another family due to loss of housing, economic hardship or similar
reason?
CI Yes
0 No
Questionaire
•
Does anyone in your household work, or has anyone ever worked in seasonal or temporary work related to
agriculture (such as fieldwork), food processing (such as canneries or packing houses), fishing, lumbering,
or dairy work in the last three years? CI No 0 Yes (If yes, complete Pink Migrant Education Card)
•
•
•
•
•
Has student ever received Special Education Services?
Has student ever received 504 accommodation(s)?
Has student ever received English Learner Services?
Has student ever been retained or advanced a grade?
Has student ever attended San Marcos schools before?
•
Has the student been previously suspended or expelled or is he/she currently recommended for expulsion?
O No
0 Yes School Name:
CI No 0 Yes
CI No CI Yes
CI No CI Yes
CI No 0 Yes What grade:
E3 No CI Yes School Name:
Last School Attended
School Name:
Address of Last School:
Street
Fax:
Phone:
City
Zipcode
Please complete only if student is enrolling in Kindergarten
•
Please select the program in which your child was primarily participating in prior to Kindergarten. (check one)
O Educational Enrichment Systems (EES) Preschool Program at San Marcos Unified. Name of School
O Head Start Program or other State/Federal subsidized care
O Private or Center-Based childcare program (e.g., KinderCare of a Faith-Based Preschool)
O Other
0 No Preschool
• How many months did the student participate in the program selected above?
• How often did the student attend the educational program selected?
O 1 day per week ❑ 2 days per week 0 3 days per week
❑ 4 days per week
months
0 5 days per week
Parent/Guardian Information
The California Education Code requires schools to gather information regarding the highest level of education achieved by the parent
with the most schooling.
Relationship
Full Name
Phone-Home
Phone-Work
Phone—Cell
Email:
Parent Education Level:
❑
❑
Not a High School Graduate
College Graduate
O High School Graduate
❑
Graduate School/Post Grad.Training
0
0
Some College
Decline to state/Unknown
Parent contact allowed:
O Ed. Rights
O Mailings allowed
O Contact Allowed
❑ Lives with
Relationship
Full Name
0 Has Custody(recent court papers in file)
Phone-Work
Phone—Cell
Phone-Home
Email:
Parent Education Level:
O Not a High School Graduate
0 College Graduate
O
O
High School Graduate
Graduate School/Post Grad.Training
0
0
Some College
Decline to state/Unknown
Parent contact allowed:
O Contact Allowed
O Lives with
O Ed. Rights
O Mailings allowed
0 Has Custody(recent court papers in file)
Emergency Contacts (LOCAL)
Name
Relationship
Emergency Phone Number
Name
Relationship
Emergency Phone Number
I certify that all the information on this form is true and correct. Falsification of any information or document required for the
enrollment of your child in the San Marcos Unified School District may result in denial of this application.
Parent/Guardian Signature
2/2012
Date
Carrillo Elementary School
• Jamm.
COLTS: Community of Learners Target Success
Student Health History
Grade
Birthdate
Name
First Name
Last Name
1. Medical History: ( Check if child has had a history of disease or condition)
❑ ADD or ADHD
❑
Tuberculosis
❑
frequent ear infections
❑ Head injury
❑
Bone & Joint Problems
❑
Hepatitis
Heart Condition
❑
Kidney Problems
❑ Fainting Spells
❑ Seizures
❑
❑
Blood Condition
❑ Asthma (Do you intend to have an inhaler in the Health Office?)
❑Yes ONo
0 Other
2. Please use this space to explain items checked above.
•
3. Does your child have allergies? ❑Yes ONo If "Yes" explain:
4. Does your child have any health problems now? ❑ Yes ONo If "Yes" explain:
5. Is your child taking any medication? ❑Yes
If "Yes," name of medication:
Reason for medication
ONo
Will your child taking medication at school? ❑ Yes
Would you like a district nurse to contact ydu? Dyes
Parent/Guardian
Signature
ONo
Date
School Site Only-Place Label here
Grade
D.0 B.
Please Check here if
SAN MA COS
UNiFIED SCHOOL DISTRICT
engaging students...inspiring futures
Stu #
New Student
❑ New Address
fl New Phone Numher(s)
2014-15 ANNUAL RESIDENCY 'VERIFICATION AND CHECKLIST
In accordance with District policy, all students in the San Marcos Unified School District must provide TWO residency verifications
(proof of where you live) each year in order to register. Proof of where you live must be provided at registration or your child will not
be able to register (one from each Category-see below). Proof must show Parent/Guardian/Caregiver name and address. If you want
to keep your original document(s), you must provide us with a copy to keep.
ID#:
STUDENT NAME:
Middle
Last,
First
Student living with (check one): ❑ PARENT(S)
❑ LEGAL GUARDIAN/FOSTER PARENT (need court papers)
❑ CAREGIVER (need SMUSD affidavit) )
❑ OTHER
❑ SHARED HOUSING (homeowner/renter must complete Affidavit of Residency Form)
PARENT/GUARDIAN NAME(S) (PRINT): 1.
2.
Names of Students living in the home:
I AFFIRM THAT THE STUDENT RESIDES AT THE ABOVE STREET ADDRESS:
Street Address
City
Zip Code
Signature of Person Establishing Residency
Cell Phone# for
Home Phone#
Date
*WARNING: INCORRECT INFORMATION WILL RESULT IN YOUR STUDENT BEING DISENROLLED IMMEDIATELY*
Check off one proof of residency in each category below. Proof must be current (dated within last 60 days). Each Proof
must show Parent/Guardian name and address unless shared housing (complete Affidavit of Residency Form).
**IF YOU ARE IN A TRANSITIONAL LIVING CIRCUMSTANCE, PLEASE ASK THE SCHOOL SITE FOR ASSISTANCE.
CATEGORY ONE:
❑ MORTGAGE STATEMENT or PAYMENT RECEIPT (with address of residency)
❑ RENTAL AGREEMENT or PAYMENT RECEIPT (with address of residency)
❑ PROPERTY TAX STATEMENT or RECEIPT (with address of residency)
❑ GRANT DEED (with address of residency)
❑ ESCROW PAPERS (with address of residency)
AND
CATEGORY TWO:
❑ CURRENT UTILITY BILL (SDG&E, WATER, TRASH OR CABLE)
❑
❑
❑
❑
CORRESPONDENCE FROM A GOVERNMENT AGENCY
VOTER REGISTRATION
CURRENT PAY STUB W/ADDRESS
AFFIDAVIT OF RESIDENCY (needed if shared housing-Parent/
Guardian not listed on proof of residency)
❑ OTHER
rev.1/13/14
Verifying School Official
Date
SAN MARCOS UNIFIED SCHOOL DISTRICT
STUDENT EMERGENCY CARD
Year:
Grade:
Teacher:
ID#:
X
Birthdate
Middle Name
First Name
Last Name
X
Home Phone
Home Address
Parent E-Mail Address
IN CASE OF AN EMERGENCY, IT IS IMPORTANT FOR THE SAFETY OF YOUR CHILD THAT WE HAVE INFORMATION REQUESTED BELOW.
1.
Name (Parent)
Employer
Cell Phone
Work Phone
Name (Parent)
Employer
Cell Phone
Work Phone
2.
IT IS VERY IMPORTANT, IN CASE PARENTS CANNOT BE REACHED, THAT TWO (2) ADDITIONAL NAMES AND TELEPHONE NUMBERS BE LISTED BELOW:
3.
4
Alternate Local Contact Name
Relationship
Phone
Alternate Local Contact Name
Relationship
Phone
.
IF NONE OF THE ABOVE IS AVAILABLE, YOUR CHILD WILL BE TRANSPORTED BY AMBULANCE TO THE HOSPITAL.
Siblings in school:
Name
School
Grade
Name
School
Grade
Name
School
Grade
Name
School
Grade
HEALTH CONDITION(S)- Check all that apply
ALLERGIES- Check all that apply
IF NO HEALTH PROBLEMS check here
IF NO KNOWN ALLERGIES check here
■
■ Bee Sting Allergy
■ Food Allergy, list foods:
■ ADHD
■ Asthma, needs Inhaler at school: ■ Yes ■ No
■ Diabetes, needs Insulin at school: ■ Yes a No
■ Heart Problem, explain:
■ Seizure Disorder, explain:
❑ Known Hearing Loss , wears hearing aide(s): ■ R ■ L
■ Vision Problem ■ Wears Glasses ■ Wears Contact Lenses
• Other Health Problem, explain:
MEDICATION(S)- List medications below. IF NONE, Check Here
Medication name/dose/time taken:
■
■
■ Medication Allergy, explain:
■ Other Allergy, explain:
■ Check here if your child has had an Anaphylactic Reaction
Does your child require medication to treat allergies: ■ Yes ■ No
•
IF MEDICATIONS ARE REQUIRED TO TREAT AN ALLERGIC REACTION, PLEASE
CONTACT THE SCHOOL HEALTH OFFICE OR CHECK THE SCHOOL WEB SITE TO
OBTAIN THE REQUIRED FORMS.
■
No
Are any of the listed medications taken at school?
Yes
IF MEDICATIONS ARE REQUIRED AT SCHOOL, A SIGNED PARENT PERMISSION FORM AND PHYSICIANS ORDER IS REQUIRED. PLEASE
CONTACT THE SCHOOL HEALTH OFFICE OR CHECK THE SCHOOL WEB SITE TO OBTAIN THE REQUIRED FORMS.
MEDICAL CARE PROVIDER PHONE NUMBERSPhysician Name/Phone:
Does your child have Health Insurance?
■ Yes ■ No
Dentist Name/Phone:
Name of Insurance Provider:
THE HEALTH INFORMATION PROVIDED IN THIS FORM MAY BE SHARED WITH APPROPRIATE SCHOOL PERSONNEL ON A NEED-TOKNOW BASIS IN ORDER TO PROVIDE FOR YOUR CHILD'S SAFETY AND WELL-BEING.
PLEASE CONTACT THE SCHOOL NURSE WITH ANY CONCERNS OR QUESTIONS IN THIS REGARD.
Signature(s) of Parent(s) or Guardian(s):
Date:
My signature above indicates that I understand that I am responsible for verifying any ABSENCE for the above named student.
Rev. 2/4/2013
DISTRITO ESCOLAR UNIFICADO DE SAN MARCOS
TARJETA DE EMERGENCIA DEL ESTUDIANTE
Year :
Grade:
Teacher :
ID #:
X
Nombre
Apellido
Fecha de Nacimiento
X
Telefono de casa
DOMICili0
Direction de Correo Electronic°
EN CASO DE EMERGENCIA. ES IMPORTANTE PARA LA SEGURIDAD DE SU NINO QUE TENGAMOS LA INFORMACION SOLICITADA EN ESTA TARJETA.
1.
Nombre (Padres)
Empleador
Telefono Celular
Telefono del Trabajo
Nombre (Padres)
Empleador
Telefono Celular
Telefono del Trabajo
2.
ES MUY IMPORTANTE, EN CASO QUE LOS PADRES NO PUEDAN SER CONTACTADOS, QUE (2) DOS NOMBRES Y NUMEROS DE TELEFONO ADICIONALES
SE PROPORCIONEN. POR FAVOR INDIQUE A CONTINUACION:
3.
Nombre del contacto alternativo (local)
Relation
Telefono
Nombre del contacto alternativo (local)
Relation
Telefono
4.
SI NINGUNA DE LAS PERSONAS EN LA LISTA ESTA DISPONIBLE, SU NINO/A SERA TRANSPORTADO POR AMBULANCIA AL HOSPITAL.
Hermanos en la escuela:
Nombre
Escuela
Grado
Nombre
Escuela
Grado
Nombre
Escuela
Grado
Nombre
Escuela
Grado
CONDICIONES MEDICA(S)- Marque todo que aplica
SI NADA APLICA marque aqui
■
■ ADHD
■ Asma, necesita inhalador en la escuela: ■ si ■ no
❑ Diabetes, necesita insulina en la escuela: •si ■ no
■ Enfermedades cardiacas:
■ Historia de ataques epilepticos:
■ Perdida de la audition, usa audifono(s): ■ R ■ L
■ Problemas de la vista ■ usa lentes ■ usa lentes de contacto
ALERGIAS- Marque todo que aplica
■
■ Reaction a picaduras de abeja
■ Alergia de comida o otra alergia (por favor lista):
Si no hay alergias conocidas marque aqui
■ Alergia de medicina, explique:
■ Otra alergia explique:
• Marque aqui si su hijo/a ha tenido una reaction anafilactica
Requiere su hijo/a medicamentos para tratar las alergias:
Ills(
❑ Otro problema de salud:
■ no
SI SE REQUIEREN MEDICAMENTOS PARA TRATAR UNA REACCION
ALERGICA, POR FAVOR COMUNIQUESE CON LA OFICINA DE LA ESCUELA
0 VISITE EL SITIO WEB DE LA ESCUELA PARA OBTENER LAS
FORMULARIOS NECESARIOS.
MEDICAMENTOS- Lista de medicamentos. Si no toma ninguno marque aqui:
■
Nombre de medicamento/dosis/tiempo de uso:
Es alguno de las medicamentos indicados usado en la escuela?
■ si
Ono
SI LOS MEDICAMENTOS SON NECESARIOS EN LA ESCUELA UNA FORMA DE PERMISO DE LOS PADRES FIRMADO V PARA LOS MEDICOS
ES NECESARIO, PONGASE EN CONTACTO CON LA OFICINA DE SALUD ESCOLAR PARA OBTENER LAS FORMAS NECESARIAS.
Numeros telefonicos de proveedores medicos:
Nombre de dentista/telefono:
Nombre del medico/telefono:
Tiene su hijo/hija seguro medico?
■ si ■ no
Nombre del proveedor de seguro:
LA INFORMACION DE SALUD PROPOCIONADA EN ESTE FORMULARIO PUEDE COMPARTIRSE CON EL PERSONAL EXCOLAR
APROPIADO CUANDO SEA REQUERIDA CON EL FIN DE GARANTIZAR LA SEGURIDAD Y BIENESTAR DE SU HIJO/A.
POR FAVOR PONGASE EN CONTACTO CON LA ENFERMERA DE LA ESCUELA SI TIENE ALGUNA DUDA 0 PREGUNTA AL RESPECTO.
Firma de los padres o tutores:
Fecha:
Mi firma indica que entiendo que yo soy responsable de verificar cualquier ausencia del estudiante aqui indicado.
Rev. 2/4/2013
SAN MARCOS
UNIFIED SCHOOL DISTRICT
engaging students...inspiring futures
Student Services
255 Pico" Avenue, Suite 250
San Marcos, CA 92069
T 760.752.1299
F 760,752.1215
www.smusd.org
Dear Parent or Guardian:
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) in kindergarten or first grade, whichever is his or her first year
in public school. Dental assessments completed up to 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.
Please take the attached Oral Health Assessment/Waiver Request form to the dental office, as it will be needed for
your child's check-up. The following resources will help you find a dentist and complete this requirement for your
child:
Medi-Cal/Denti-Cal's toll-free number or Web site can help you find a dentist who takes Denti-Cal: 1-800322-6384; http;//www denti-cal.ca.gov
2. Covered California's toll free number or Web site can help your find a dentist or find out if your child can
enroll in the program: 1-800-300.1506; http://www.coveredca ,com
3. For help in enrolling in either Medi-Cal/Denti-Cal or Targeted Low Income Children's Program you may call
the San Diego Maternal, Child and Family Health Services toll free help line at 1-800-675-2229, Listen for
the SD-KHAN option.
4, For additional resources to find a provider:
a. San Diego Kids Health Assurance Network © 1-800-675-2229. http://www.sdkhan.org
b. 2-1-1 San Diego (If you are urtable to reach 2-1-1 from your cell phone or you are calling from
outside San Diego County, please call 858-300-1211.
c. San Diego Dental Society 619-275-0244.
1.
Remember, if your child has poor dental health, your child is not healthy and ready for school. 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.
•
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 Type 2 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.
Your cooperation with this new law is very much appreciated. If you have questions about the oral health
assessment requirement, please contact David Cochrane in Student Services at 760-752-1221.
If you cannot take your child for this required assessment, please indicate the reason for this in Section 3 of the form.
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.
Sincerel
Kevin D. Holt, Ed.D
District Superintendent
Attachment
Governing Board:
Beckie Garrett
Pam Lindamood
Janet McClean
Kevin D. Holt, Ed.D. Superintendent
Jay Petrek
Randy Walton
1
"7 1 SAN MARCOS
UNIFIED 5`H001 DISTRICT
engaging students...inspiring futures
Student Services
255 Pico Avenue, Suite 250
San Marcos, CA 92069
T 760.752.1299
F 760.752.1215
www.smusd.org
Dear Parent or Guardian:
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) in kindergarten or first grade, whichever is his or her first year
in public school. Dental assessments completed up to 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.
Please take the attached Oral Health Assessment/Waiver Request form to the dental office, as it will be needed for
your child's check-up. 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 find a dentist who takes Denti-Cal: 1-800322-6384; http://www.denti-cal.ca.gov
2. Covered California's toll free number or Web site can help your find a dentist or find out if your child can
enroll in the program: 1-800-300-1506; http://www.coveredca.com
3, For help in enrolling in either Medi-Cal/Denti-Cal or Targeted Low Income Children's Program you may call
the San Diego Maternal, Child and Family Health Services toll free help line at 1-800-675-2229. Listen for
the SD-KHAN option.
4. For additional resources to find a provider:
a. San Diego Kids Health Assurance Network @ 1-800-675-2229. http://www.sdkhan.org
b. 2-1-1 San Diego (If you are urtable to reach 2-1-1 from your cell phone or you are calling from
outside San Diego County, please call 858-S00-1211.
c. San Diego Dental Society 619-275-0244.
Remember, if your child has poor dental health, your child is not healthy and ready for school. 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.
•
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 Type 2 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.
Your cooperation with this new law is very much appreciated. If you have questions about the oral health
assessment requirement, please contact David Cochrane in Student Services at 760-752-1221.
If you cannot take your child for this required assessment, please indicate the reason for this in Section 3 of the form.
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.
Kevin D. Holt, Ed.D
District Superintendent
Attachment
Governing Board:
Beekie Garrett
Pam Lindamood
Janet McClean
Kevin a Holt. Ed.D. Superintendent
Jay Petrek
Randy Walton
Child Bealth and Disability Prevention (CHDP) Program
County of San Diego
Report of Medical Examination for School Entry
California law requires a medical examination for school entry to protect the health of all children.
Please return this report to the school. All personal information will be kept confidential.
PART I TO 1W FILLED OUT BY PARENT OR GUARDIAN/ Espanol al tlurso
School
Middle Initial
First
CHILD'S -NAME—Last
ADDRESS Number, Street
ZIP Code
City
: Birth Date--,-Month/Day/Year
❑ I want the medical provider to complete Part II and Part III
❑ I want the medical provider to complete Part II only
Date
Signature of Parent or Guardian
13\"111E MEDICAL. PROVIDER
PART 11 TO BE. FII .I.ED
Date
Tests and Evaluations
Child's Height
Child's BM1
Percentile
Child's Weight
inches
Ilealth/Developinent History
lbs
Medical Provider Information
Name, Address, and Telephone Number:
ozs
Physical Examination
Nutritional Evaluation
Vision Screening
Audioinetric Screening
Blood Test for Anemia
Urine Dipstick
Dental Screening
Tuberculin (TB) Skin 'rest
(Recommended for AU, children entering first grade)
Signature of Medical Profassional Date
CHILD HAS A COMPLETED OR UPDATED YELLOW CALIFORNIA IMMUNIZATION RECORD
❑ YES ❑ NO
PART Ill TO BE E1LLED OUT BY THE MEDICAL PROVIDER
Other Health Information (Optional): For the child's welfare—and with the permission of the parent or guardian—it is
recommended that significant health information be shared with the school. Please contact the school nurse if the child needs help
with medication at school.
'0 Parent requests Part III not be filled out ❑ The examination revealed no conditions of importance to school or physical activity.
❑ Conditions that need further evaluation or that can affect school or physical activity are (please explain):
WAIVER OF MEDICAL EXAMINATION
Note: Your child must have immunizations required by State law, even if no health examination is given.
I have been told about the medical examination recommended by health professionals and required by State law. 1 have also
been told where and how my child can receive medical examinations at no cost, if such assistance is needed.
I do not want my child to receive a medical examination
I do want my child to receive a medical examination, but I am unable to get it because
Signature of Parent or Guardian
Date
County of San Diego Health and Human Services Agency, 3851 Rosecrans Street, Suite 522, MS: P51141, San Diego, CA 92110
For more information, please call 619-692-8808
MCFHS-77 ES 4/08
Oral Health Assessment Form
T07-003, English, Anal Font
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:
i Middle Initial:
I
Last Name:
Child's birth date:
Address:
Apt.:
City:
ZIP code:
Grade:
Child's Sex:
❑ Male
School Name:
Teacher:
Parent/Guardian Name:
Child's race/ethnicity:
Black/African American
❑ Hispanic/Latino
❑ White
❑ Native American
Multi-racial
❑ Other
❑ Unknown
❑ Native Hawaiian/Pacific Islander
❑
❑
❑ Female
Asian
❑
Section 2: Oral Health Data Collection (Filled out by a California licensed dental professional)
IMPORTANT NOTE: Consider each box se arate Mark each box.
Assessment
Date:
Caries Experience
(Visible decay and/or
fillings present)
Visible Decay
Present:
❑ Yes
❑ Yes
o No
❑ No
Licensed Dental Professional Signature
Treatment Urgency:
❑ No obvious problem found
❑ Early dental care recommended (caries without pain or infection;
or child would benefit from sealants or further evaluation)
❑ Ur ent care needed (pain, infection, swelling or soft tissue lesion
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
o 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: 111.
Signature of parent or guardian
Date
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
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.
Y NP 2
L
P
Carrillo Kindergarten /Teacher Reference Card
Child's Name
Boy/Girl
Name to be used in school
Birthday
Age(years/months) on start day
Home Phone
E-mail
Mother's name
Cell
Father's name
Cell
Will your child be attending after school care? If so , where and on what days?
Fri
Thurs
Mon
Tues
Wed
Attended Preschool: yes or no
If yes, which one?
Was it mostly(circle): full day/ part time?
Years/Months?
Did they have any concerns or problems that you think we should know about?
r
W i ll a parent/grandparent be able to help in the classroom?
monthly
Circle one: weekly
alternate weekly
maybe No
Please circle one. My child is mostly:
1. LEARNING LETTERS/SOUNDS 2. KNOWS most LETTERS/SOUNDS
3. STARTING TO READ 4. READING 5. FLUENTLY READING
Can your child print their name by themselves?
Is remembering songs and rhymes
for your child?
Circle one: easy
somewhat easy
somewhat difficult
What language does your child hear most a home?
What language does your child speak the most?
Would you consider your child a follower or a leader?
Is your child right or left handed?
difficult
Y NP 2
L
P
Does your child have any special needs we need to know about (Food allergies,
unusual habits, health concerns, special services-speech/OT, recent death/divorce)?
Do both parents live in the home? Yes or No
If shared custody, what is your child's living arrangement?
Does you child have any siblings? If yes, complete chart below:
Name
Age •
School/grade
Same household
What do you see as your child's strengths?
What do you see as your child's weaknesses?
What challenges do you have most with your child?
Check Characteristics (if any) that apply to your child:
•Temper tantrums
Cries easily
Bites hills
Sulks
Destructive
Daydreams
Sucks thumb
Fearful
What do you hope your child gains from this year?
Is there anything else you want us to know?
Sleeping problems
Whines
Sleeping Problems
Jealous
Carrillo Elementary School
Kindergarten Readiness Activities
Things for them to do. They should practice:
writing name independently.
tying shoes independently.
using glue bottles, coloring and stringing objects.
recognizing and naming alphabet letters out of order.
(use flashcards, food packages, catalogues and magazines. Leap Frog's Letter
Factory is a great DVD that teaches letters and sounds very quickly)
recognizing the following basic colors: purple, blue, green, yellow, orange, red,
brown, black and white.
recognizing numerals 0 through 10 out of order. (You can use flash cards)
counting objects accurately to 10.
sitting and listening to a story for 10-15 min.
waiting their turn to speak and share.
Things they must be able to do.
They must be able to take care of bathroom needs.
They should memorize your phone number.
Things you can do.
Read to your children every night
story, you have just read to them .
' , III
On occasion, ask your child to 'retell' you the
You can assign some simple responsibilities to your child (2 and 3 step tasks).
Ask your child to make-up stories of his or her own, while you record what they say.
We are so excited about your child starting Kindergarten here at
Carrillo Ele: _entary and look forward to se- ing you in this year!
SAN MARCOS UNIFIED SCHOOL DISTRICT
KIDS ON CAMPUS
***KOC registration packets for 2014-2015 will not be available until March 19 2014***
We recommend that you enroll as soon as possible (on or after KOC registration date 3/19) to ensure a spot.
The Kids On Campus program of the San Marcos Unified School District offers on-site
childcare for children enrolled in the following elementary schools:
Knob Hill
Before and after school care when school
is in session (including Kindergartners)
San Elijo
Twin Oaks
No Camp (vacation care) but children may attend
Camp at our other sites
Carrillo
Discovery
Before and after school care when school
is in session (including Kindergartners)
La Costa Meadows
Full day care (Camp) during vacations
Paloma
Richland
Space is limited and no child is guaranteed a spot .
Enrollment in KOC is accepted on a first come, first served basis. All children must be registered for
each school year, whether or not they have attended previous years.
Our centers are open from 6:30 a.m. to 6:00 p.m. Monday through Friday. We are
closed on all school holidays. There is an annual registration fee. Minimum enrollment
is three days per week and schedules must be the same each week. You may enroll
for just mornings, just afternoons, or mornings and afternoons. (For example, you
cannot enroll for Monday and Tuesday mornings and Wednesday and Thursday
afternoons.) Children must be signed in when they arrive at KOC before school and
signed out after school. We cannot accept children from the bus nor can we release
them to the bus. Tuition is due on the first day of each month and late after the 10th.
Camp care must be signed up for separately.
For more information please call the District Office at 760-752-1279.
Kindergarten children must be registered at the school before registering for KOC.
Parents of Kindergarten children should NOT wait until they know whether they get AM or PM
Kindergarten to register for KOC. Register based on what you have requested.
We can usually adjust schedules for the middle of the day - but the late afternoons may fill up quickly.
ALWAivnA4141/ EIRAneinta.0/
S thocti.
3697 Lcvl1/441rad,ct/DriNei, San/Mai/co-16 CA 92078
(760) 290-2000
Je.wnife,r- Carter, PrCnotpa-1/
Date: February 6, 2014
To: All SMUSD families with incoming Kindergarten Students
From: Jennifer Carter, Principal at Alvin Dunn Elementary School
Alvin Dunn Elementary is extremely honored to be recognized as an International Baccalaureate
Primary Years Program Candidate School. The International Baccalaureate Program (IB) is
renowned throughout the world for its academic rigor and focus on global mindedness. In the
Primary Years Program, a balance is sought between the acquisition of essential knowledge and
skills, development of conceptual understanding, and the demonstration of positive attitudes, and
responsible action. Our school will be applying for full IB World authorization in the 2014-15
school year and again this year, we will be accepting transfers to Alvin Dunn.
In the upcoming 2014-15 school year, we will have 25 available openings for Kindergarten in the
International Baccalaureate Program and are offering this opportunity for interested families
throughout the district. Our Kindergarten program is unique. We have an extended day
program in which all students attend school from 8:45am to 2:10pm daily. This extension of the
day allows for additional enrichment classes, such as Spanish, Art and Technology, all which are
part of the IB program. Our teachers are committed to increasing our student's knowledge of the
core curriculum by engaging them in units of study that are relevant, challenging and globally
significant. As with all SMUSD schools, we ensure success by applying the best instructional
practices which include differentiated instruction at all academic levels. We understand that
education is critical to the future success of our students therefore we strive for them to become
active, inquiring, life-long learners who will be prepared for college and career as well as for
global citizenship.
If you are interested in your child joining the International Baccalaureate Program at Alvin Dunn
Elementary for Kindergarten, you will need to first register at your home school. Next, you will
need to fill out an intra-district transfer form. Please include IB program as your reason for the
transfer on your transfer request. You can obtain these forms from our Student Services
Department at the district office at 255 Pico Ave in San Marcos. In addition you will need to
make the commitment to transport your own student to Alvin Dunn Elementary. If more than 25
students complete intra district transfers for Kindergarten there will be lottery held on April 25 th .
Yvonne Fojtasek, our International Baccalaureate Coordinator will be hosting tours of our
program on the following dates March 5, March 26, April 9, April 22, and May 7. All tours will
be held from 9am to 10am. If you would like to sign up for a tour, you may call the office at
760-290-2000 or you may email Mrs. Fojtasek at vvonne.foitasek(cD,smusd.org . There is also
additional information about our school on our website www.alvindunnelementary.org .
1111111011111
Most children expect to see candy and cake at classroom birthday celebrations or
events, however too many empty calories cause obesity and other health problems.
Since our District Wellness Policy teaches our students the importance of a healthy
lifestyle, we want to send a consistent message that good nutrition goes hand and
hand with academic success. To support this message, please promote non-food
birthday celebrations and healthy snacks for classroom celebrations; thus shifting
the focus from the food to the student or event.
Healthy Birthday Ideas
Healthy Classroom Snack Ideas
- Parents can wrap their child's favorite book in birthday
wrapping paper. The child can unwrap the book and the
teacher can read it to the class.
- Create a "Celebrate Me" book. Have classmates write stories
or poems and draw pictures to describe what is special about
the birthday child.
- "Ants on a log" celery with
rasins and peanut butter (consider
allergies)
- Vegetables with low-fat dip
- Whole wheat pita bread or
crackers with hummus or bean
dip
- Cheese and salsa quesadilla
- Fruit smoothies
- Yogurt splits with bananas,
yogurt,
granola and fruit toppings
- Popcorn (air popped)
- Graham or goldfish crackers
- Fruit bars (no less than 50% fruit
juice)
- Low-fat string cheese
- Trail mix (consider allergies)
- Baked tortilla chips with
Birthday child can:
- Bring their favorite toy to share with the class.
- Wear a sash and crown and sit in a special chair for the
day.
- Lead their favorite physical activity outdoors.
- Be the teacher's assistant for the day.
Healthy Classroom Event Ideas
- Watch an educational video as a class and serve popcorn
(air popped).
- Order a Pizza or Sub Sandwich Luncheon from Child Nutrition
Services (CNS).
- Put on some music and have a dance contest.
- Gardening party (visit the school garden, plant a seed, etc.).
- Schedule a field trip to tour the school cafeteria, local
farmers market, grocery store or farm.
543T ION
U
Healthy Beverage Ideas
Water
Nonfat or lowfat milk
100% fruit juice
SPECIAL OFFER FOR TEACHERS
BECOME OUR FRIEND ON FACEBOOK 0 FACEBOOK.COM/CNSSMUSD AND POST
A PHOTO OF YOUR CLASSROOM'S HEALTHY CELEBRATION TO BE ELIGIBLE FOR
A CNS SPONSORED HEALTHY CLASSROOM BREAKFAST OR SNACK SOCIAL.
For more information, please contact:
Kelly Bowman, Supervisor of Nutrition Ed & Marketing
(760) 752 - 1297 [email protected]
www.smusd .org/wellnesspolicy
Join us on
facebook
facebook.comtcnssmusd
SAN MARCOS
UNIFIED SCHOOL DISTRICT
engaging students...inspiring futures
Made possible by funding from the U.S. Department of Health and Human Services, through the County of San Diego.
w
La mayoria de los ninos esperan tener dulces en cumpleanos o eventos, sin embargo,
tantas calorias son la causa de obesidad y otros problemas de salud. La Politica de
Bienestar de nuestro Distrito enseiia a los estudiantes la importancia de un estilo de
vida saludable, queremos enviar un mensaje congruente ya que la buena nutrition y el
6xito academic° van mano a mono. Para apoyar este mensaje, por favor promueva
refrigerios saludables para los eventos en los salones de close y los cumpleafios, asi se
cambia el enfoque hacia el estudiante o evento y no en Ia comida.
Ideas para un Cumpleatios Saludable
- Padres: envuelvan el libro favorito de su hijo en papel de
cumplearios. Su hijo puede desenvolverlo en el salon
para que el maestro lo lea
- Construyan un libro titulado: "Celebrenme". Haga que
los compaiieros de salon escriban historias o poemas y
dibujos que describan porque es especial el cumplecuiero.
El cumplealiero podra:
Traer al salon su juguete favorito.
Vestir corona, banda y sentarse en un lugar especial.
Dirigir su actividad favorita.
- Ser asistente del maestro en ese dia.
- Venir a times con su disfraz favorito.
Ideas para Eventos Saludables
- Muestre a Ia clase un video educativo y sirven palomitas.
Ordenar Pizza o Sub Sandwiches al Servicio de Nutrition
Infantil (CNS).
- Tom musica y tener un concurso de baile.
- Fiesta en el jardin (visitor el jardin de la escuela o sembrar
una semilla)
- Planee un viaje de campo a la cafeteria de la escuela o al
mercado local.
Ideas para Refrigerios
Saludables
"Ants on a log" apio con pasas y
crema de cacahuate (considere
alergias)
- Verduras con dip bajo en grasas
- Pan pita de trigo integral o galletas
saladas con hummus o dip de frijoles
- Quesadilla con salsa
- Licuado de frutas
- Yogurt con platano, granola o frutas
variadas.
- Palomitas de maiz reventadas por
aire caliente
-
- Galletas goldfish o de salvado
Paletas de frutas (al menos 50% de
fruta)
Queso bajo en grasa
- Mezcla de nueces (considere alergias)
- Tortillas horneadas con guacamole o
salsa
- Rebanadas de manzana con queso
- Brochetas de frutas
■ Ideas de Bebidas Saludables
Agua
Leche descremada o sin grasa
Jugo 100% de fruta
OFERTA ESPECIAL PARA PADRES
SEA NUESTRO AMIGO EN FACEBOOK: FACEBOOK.COM/CNSSMUSD
MANTENGANSE INFORMADO ACERCA DE EVENTOS Y ACTIVIDADES DEL
"c„;
DISTRITO Y DE SU ESCUELA RELACIONADOS CON LA POLITICA DE BIENESTAR
Para mas information comuniquese con:
Kelly Bowman, consultor de education de nutrition
(760)752 1297 o [email protected]
www.smusd.org/wellnesspolicy
-
Join us on
facebook
facebook.comlonssmusd
F7172—'
SAN MARCOS
UNIFIED SCHOOt DISTRICT
engaging students...inspiring futures
Hecho posible con fondos del Departamento de Salud y Serivicios Humanos de EEUU a troves del Condado de San Diego
2014-2015
R
E
T
U
R
N
T
0
SPECIAL NUT ALLERGY APPROVAL LIST
N
S
School/Escuela:
Student ID Estudiante :
Grade/Grado
Although CNS has removed peanut butter entrees from the elementary menus, be advised that there are other
products being served in all cafeterias that may contain traces of nuts or are manufactured in a facility that
processes nuts. Secondary cafeterias offer product that contain nuts. Please review the list below for items
currently served and known to contain nuts as an ingredient. Please request ingredient documents, if
necessary, by contacting CNS at (760) 752-1254.
CNS ha eliminado platos de mantequilla de cacahuate en toda las menus en escuelas de primaria. Tenga en
cuenta que hay otros productos que se sirve en la cafeteria, que puede contener cacahuate o ha sido
fabricado en una facilidad que procesa cacahuate. Cafeterias en escuelas secundarias sirven comidas que
contienen cacahuate. La lista que sigue son alimentos que se sirve en In cafeteria y pueden contener
cacahuate como tin ingrediente. Si necesita mas informaci6n es necesitada acerca de ingredientes. por favor
de Ilamar CNS al (760) 752-1254.
SECONDARY--MIDDLE & HIGH SCHOOLS
Breakfast
Breakfast / Desavundo
Honey Nut Scooters (like Honey Nut Cheerios)
NONE / NADA
Peanut Butter & Jelly Bar
Lunch / ALMUERSE
M
M
E
D
A
-
Student Name/Nombre:
ELEMENTARY SCHOOLS
C
SMUSD CNS
NONE / NADA
Sandwich de crema de Cacahuate y mermelada
(all elementary no longer serve pbj 8/24/11)
Lunch
(las escuelas primaria no serviran
Peanut Butter & Jelly Sandwich
Sandwich de crema de cacahuate y mermelada
cacahuate efectivo 8/24/11)
Asian Noodle Salad--Ensalada de fideos chinos
Crackers / Galletas
NONE/NADA
Snacks Available for Purchase
E
L
Y
Granola Bar Peanut Butter and Chocolate
(Quaker 25% less sugar--no high fructose corn syrup)
(Barra de granola, cacuhuate y chocolate)
*NOTE: Manufacturers can change
* NOTA : Los fabricantes pueden cambiar
ingredientes notificaciones a Servicios de
NutriciOn Ninos pueden ser demoradas. (Esto
se aplica a/ desayuno y almuerzo)
ingredients with a lag of notification
to Child Nutrition Services. (This
applies to Breakfast/Lunch Entrees)
*Meal menus are created as "Offer vs. Serve" and do not include student preference items. Please review the menu
choices and decide if your student will be eating in the cafeteria or bringing their own meal from home.
* Los mends estan clesigr,..7do como "Oferta contra Skye" y no incluyen prefemecias de estudiante. Por favor revise
las elections de mend para decidir si su estudiante camera en la cafeteria o trae su propia comida de casa.
My student will be eating at school on a daily basis.
Blee cheek
one and date and
sign
Mi hijo/a va corner en la escuela diario.
p,,or-f41„
/or marque
My student will not be eating at school on a daily basis.
uno yfirmap
Date/Fecha:
b,g j o
Rev.
12/20/2013
Mi hijota no va corner en la escuela
Parent/Guardian/AuthRep Name Signature
Parent/Guardian/AuthRep Name Printed
Padre/Tutor / Firma
Padre/Tutor / Nombre Escrito
Your signaure states you have reviewed the information above and approve CNS to feed your student.
He revisado el menu y apruebo lo que se ofrece a mi estudiante
760-752-1254--Patti Tice
SMUSD CNS-255 Pico Ave Ste 250
San Marcos, CA 92069
fax 760-752-1137
•
7r71
2014-2015 SMUSD CNS MEDICAL STATEMENT TO REQUEST SPECIAL MEALS AND/OR ACCOMMODATIONS PLEASE FAX DIRECTLY TO CNS - FAX# (760) 752-1137
2014-2015 DECLARACIoN MEDICA de CNS PARA SOLICITAR COMIDAS Y ALOJAMIENTOS ESPECIALES POR FAVOR ENVIE UN FAX DIRECTAMENTE a CNS (760)752 1137
-
1.
2.
NAME OF PARTICIPANT/STUDENT/NOMBRE DEL ESTUDIANTE
AGE AND/OR DOB—EDAD/FECHA DE
3.
SPONSOR/PATROCINADOR
NACIMIENTO
4.
STUDENT'S SCHOOL
SITEASCUELA DE ESTUDIANTE
SMUSD
5.
6.
SCHOOL SITE TELEPHONE NUMBER/NUMERO DE
TELEFONO ESCOLAR
NAME OF PARENT/GUARDIAN—NOMBRE DEL
7.
PADRE/TUTOR
E-MAIL PARENT/GUARDIAN—CORREO ELCTRoNICO DEL
PADRE/TUTOR
-
(760)
39. SIGNATURE OF PARENT/GUARDIAN (REQUIRED)—FIRMA DEL PADRE/TUTOR
(IMPORTANTE)
The District is required to comply with stole end federal lows protecting the rakes,' of student and medial records, including but not limited to, the family Educational Rights and Privacy Act, 20 USCI732g (FERN)
and Education Code Section 49050 et seq✓
32. TELEPHONE PARENT/GUARDIAN-
33.
TELEFONO PADRE/TUTOR (TRABAJO)
PADRE/TUTOR (CASA)
TELEPHONE PARENT/GUARDIAN—TELEFONO
WORK
HOME
TELEPHONE GUARDIAN—TELEFONO
35.
DATE SIGNED PARENT/GUARDIAN-
PECHA DE LA FIRMA PADRE/TNTOR
CELL (
WILL YOUR CHILD BE BUYING/RECEIVING MEALS FROM THE CAFETERIA? EL
40.
34.
PADRE/TUTOR (CELLULAR OR MOV1L)
)
NiNo SE COMPRA/RECIBIR COMIDAS EN LA CAFETERIA? SI 0 NO ■—■
u Yes/Si
❑ No
Note: You must have or set u. a re .aid account. Nola Usted debe tener o confi.urar una cuenta •re.a.ada
(CHECK ONE OR BOTH/MARQUE UNA 0 AMBOS)
fIMPORTANT/IMPORTANTE
❑ Not Dail /No Diana ❑ Lunch/lUrnuerzos:
Breakfast/Desa uno: 0 Dail /Diaria
❑ Not Dail /No Diarios
❑ Dail /Diarios orb
`
14. SIGNATURE OF PREPARER
15. PRINTED NAME
16. TELEPHONE NO
(
17. DATE
.
)
18. MUST CHECK ONE:
❑
❑
Participant does not have a disability, but is requesting a special meal or accommodation due to food intolerance(s) or other medical
reasons. 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. (Personal food preferences are not an
appropriate use of this form and will not be honored.)
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. (List diagnosis code below.)
19.
DISABILITY OR MEDICAL CONDITION REQUIRING A SPECIAL
A. Ingredient(s) To Be Omitted
B. Suggest Substitutions
(PLEASE UST SPECIFIC INGREDIENT (S) TO BE
(PLEASE UST SUGGESTED SUBSTITUTIONS)
MEAL OR ACCOMMODATION:
ALLERGIC TO (LACTAID MILK AVAILABLE TO ALL)
OMITTED—EX. EGG AS INGREDIENT OR WHOLE
CHECK ALL THAT APPLY AND COMPLETE A & B
ONLY, IF MILK ONLY PLEASE UST OR IF ALL DAIRY
Ti
PLEASE BE SPECIFIC)
Ti
Shellfish
❑ S oy
❑ T ree Nuts
Wheat
Egg
❑ Gluten
1:1 Milk
❑ Peanut
❑ Other
List Specific Food Groups if necessary with % of fat
(ex. <30%) or an actual amount :
❑
DiagnosisCode:
(PLEASE ATTACH ADDITIONAL SHEET IF NEEDED)
20. ALLERGY LIFE THREATENING?
21. REDUCED CALORIE Ti
11 Yes
Breakfast
22. SIGNATURE OF PHYSICIAN (REQUIRED*)
7
STUDENT HAS EPI PEN AT SCHOOL?
No
❑ Lunch
❑
Yes n
No
(Check one or both—Cafeteria will follow current procedures on file)
23. PRINTED NAME
25. FAX NO.
24. TELEPHONE NO.
26.
DATE
(REQUIRED)
INCLUDE
CLINIC NAME
AND/OR
(
STAMP
* Physician's signature is required for participants with a disability — please stamp if available or list clinic name.
SIGNATURE OF MEDICAL AUTHORITY
28. PRINTED NAME
30. DATE (REQUIRED)
29. TELEPHONE NO.
(
gDwrn.
27
(REQUIRED)(INCLUDE CLINIC OR PRACTICE NAME)
)
For participants without a disability, a licensed physician, physician's assistant, or registered nurse must sign the form. Date required.
NOTE:! The information on this form should be updated yearly to reflect the current medical and/or nutritional needs of the student
Questions:
FAX
CNS
(760)
752-1137
In accordance with Federal law and U.S. Department of Agriculture policy, this institution 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 Adjudication. 1400 Independence Avenue, S.W., Washington, DC
20250-9410, or call (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay
Service at (800) 877-8339, or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.
Rev. 12/9/13
INSTRUCTIONS SMUSD CNS 2014-2015
NOTE: Parent/Guardian—Please Complete Number 1-13 Only
Los Numeros 14 por 30 Sera Completados por un medico solo - Gracias
Name of Participant/Student: Print the name of the child or adult participant to whom the information pertains.
Nombre del Estudiante: Imprima el nombre del nifio o paricipant adulto a quien la informaciOn pertenece a.
2.
Age of Participant: Print the age and Date of Birth of the participant. For infants, please use Date of Birth.
Edad Fecha de Nacimiento: Imprimir la edad y Ia fecha de nacimiento del participante. para los bebes : por favor nos fecha de
nacimiento
3.
Sponsor: SMUSD is the name of the agency that is providing the form to the parent./ Patrocinador - SMUSD
4.
School Site: Print the name of the site where meals will be served (e.g., school site, child care center, community center, etc.)
Escuela de estudiante: Imprimir el nombre de Ia escuela donde las comidas se sirven (por ejemplo, centro de cuidado infantil. centro
comunitario)
5.
School Site Telephone Number: Print the telephone number of the site where meals will be served (#4 above)
NOrnero de telefono escolar: Imprimir el nOmero de telefono de la escuela donde se servira la comida.
6.
Name of Parent/Guardian: Print the name of the person requesting the participant's medical statement.
Nombre del Padre/Tutor: Imprimir el nombre de la persona que solicita la declaracion medica del participante.
7.
E - Mail Parent/Guardian: Print the e-mail of the parent/guardian.
Correo electrOnico del Padre/Tutor: Imprimir el correo electronic° de los padres o tutores.
8.
Signature of Parent/Guardian: Signature of Parent/Guardian completing form. Items 5-12 (Required to be complete for any student)
Firma del Padre/Tutor: Firma de los padres o tutores completando el formulario (articulos 5-12) - Necesario completar para cualquier
estudiante)
9-11. Telephone Numbers: Print the telephone numbers of parent/guardian—please list all available.
Imprimir los numeros de telefono: De los padre/tutore—enumere todas disponibles. Telefono padre/tutor (trabajo) Telefono
padre/tutor (casa) Telefono padre/tutor (cellular or mOvil)
12.
Date Signed: Date signed by the parent/guardian.
Fecha de la firma: Fecha de la firma padre/tutor.
13.
Buying/Receiving Meals from Cafeteria: Check ( ✓ ) yes or no. Breakfast and/or Lunch and how often?
1.
El nino se compra/recibir comidas en Ia cafeteria? Si o no – Marca ( ✓ )EI desayuno y/o el almuerzo y con que frecuencia?
NOTE: Medical Authority
—
Please Complete Number 14 30
-
/
Los NOrneros 14 por 30 Sera Completados por un Medico Solo - Gracias
16.
Signature of Preparer: Signature of person completing Items 1-13.
Printed Name: Print name of person completing Items 1-13.
Telephone Number: Telephone number of person completing form.
17.
Date: Date preparer signed form.
18.
Check One: Check (✓ ) a box to indicate whether participant/student has a disability or does not have a disability.
19.
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. and list diagnosis code)
Allergy to: Check ( ✓ ) a box to indicate all that apply and for Other be specific.
14.
15.
A.
B.
Ingredient(s) to Be Omitted: List specific ingredient(s) that must be omitted. For example, "exclude fluid milk."
Required Substitutions: List specific foods and food groups to include in the diet. For example, "calcium fortified juice." Be specific with % of fat (ex.
<30% or actual amount. This is helpful in determining our menu items to omit.
20.
Is Allergy Life Threatening or Severe? Check ( ✓) yes or no (Epi Pen at school? Check (✓ ) yes or no
21.
Reduced Calorie: Check ( ✓ ) breakfast and/or lunch. (Cafeteria will follow current procedures.)
Signature of Physician and Include stamp and name of clinic if applicable: Signature of physician requesting the special meal or accommodation.
22.
(Required to be complete if disability) Items 22-26
23.
Printed Name: Print name of physician.
24.
Telephone Number: Telephone number of physician.
25.
26
27.
Fax Number: Fax number of physician.
Date: Date physician signed form. (Required)
Signature of Medical Authority: Signature of medical authority completing form.
28.
Printed Name: Print name of medical authority signing form.
29.
30.
Telephone Number: i-ax number of physician.
Date: Date medical authority representative signing form. (Required)
(Required to be complete for non disability) Items 27-30
DEFINITIONS*: (Definiciones son disponibles en espanol en www.smusd/cns bajo Alergia y Solicitudes de Dieta Especial/Alergia y Documentos de Dieta Especial)
"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 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)
In accordance with Federal law and U.S. Department of Agriculture policy, this institution 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 Adjudication, 1400
Independence Avenue, S.W., Washington, DC 20250-9410, or call (866) 632-9992 (Voice). Individuals who are hearing impaired or have
speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339, or (800) 845-6136 (Spanish). USDA is an equal
opportunity provider and employer.
Rev. 12/9/13
SAN MARCOS UNIFIED SCHOOL DISTRICT
ALLERGY NOTIFICATION GUIDE
This guide is intended to assist parents with
children who have documented allergies in notifying
the appropriate departments/areas of the school
district. To ensure that all responsible
departments have been notified, please follow the
channels outlined in this guide and complete the
appropriate paperwork for each department/area.
DRIVERS / BUS AIDES
TRANSPORTATION
- Transportation request
form kw Special needs
(760) 290-2651
AREA SUPERVISOR
CAFETERIA MANAGER
<r_
HEALTH AID
CHILD NUTRITION
SERVICES
••
••
HERE
A
(DISTRICT OFFICE)
Medical Statement
Special Diet Form
4
•
SCHOOL HEALTH
OFFICE
- Emergency Card
- Medical Packet
D
T U
R R
I E
- other Required Forms
(760) 752-1254
SCHOOL ADMIN.
N
CAMPUS SUPV.
T
CLASSROOM TEACHERS
NON-SCHOOL
SPONSORED ACTIVITIES
- Boys & Girls Club
- Classroom Events
- Nutrition Advisory Council
- Field Trips
HOOL ACTIVITIES
- Boy, Gin Scouts
- Projects
- Etc.
1
"777 SAN MARCOS
UNIFIED SCHOOL DISTRICT
CENTER STAFF
engaging students...inspiring futures
NOTIFICATION CHANNELS
-
NON -FOOD ALLERGY
(PARENT'S RESPONSIBIUTY)
-
* Parent/Guardian must contact each department/area and complete all
necessary documents to ensure that allergic students can be accommodated.
FOOD ALLERGY
(PARENT'S RESPONSIBILITY)
-
FLOW OF INFORMATION
(DISTRICT'S RESPONSIBILITY)
DISTRITO ESCOLAR UNIFICADO DE SAN MARCOS
GLAA PARR LA NOTIFICACloN DE LAS AL IA
La intention de esta guia es la de asistir a los padres de familia
que tienen hijos con alergias para saber comp notificarle a los
departamentos o areas del Distrito escolar de las mismas y
que hayan sido diagnosticadas por un medico previamente.
Para asegurarnos de que todos los departamentos han sido
notificados le pedimos siga la information que se encuentra en
esta guia y Ilenar los formularies necesarios para cada
iepartarnento o area.
SUPERVISOR DEL AREA/
ENCARGADO DE LA CAFETERIA
AYUDANTE DE LA ENFERMERIA
DE LA ESCUELA
CHOFERES/
AYUDANTES DE TRANSPORTE
TRANSPORTATE
SERVICIDS DE NUTRICION
(INFANTIL)
Report? meoico
- soildtua pars una meta
- Taryeta ce emergertcla
- Paauete medico
especial
(750) 752-1254
ADMINISTRADORES DE LA
ESCUELA
ENFERMERIA DE LA
ESCUELA
SUPERVISORES
DEL PLANTEL
atras Formtilarios requerlOes
PADRE
0 TUTOR
Ocjane saber at maestro(a)
cua'quier
ale.rgia cam;
estixgante
ACTIVIDADES NO
ESCOLARES
MAESTROS(AS) DE SALON
DE CLASES
Eventos en ei saion ae oases
- consoos oars is wena nurrscion
- Paseos escoiares
- El club de Boys and Girls
- Los scouts nlnos o nines
- Etc.
ACTIVIDADES
ESCOLARES
NUS) OS EN EL PLANTEL
ESCOLAR (KOC)
-P
(rtes
a
- Asociaclon eel Estudlante
- Paquete Ce iftscripcion
(750) 752 - 279
PERSONAL DEL CENTRO
Pr
SAN MARCOS
UNIFIED scHoot DISTRict
DE KOC
engaging students...inspiring fuiures
NOTiFiCATION CHANNELS
- ALMENFOS OLE NO CAVAN ALERGIAS
(PESPONSAIICIDAD DE LOS 1,ACRE5)
00 IP • • ALMENTOS DUE CAtbAN 0.1.ERGAE,
(RESPON5AEMID tXLOSPADRE5)
* El padre o tutor delde ponerse en contact° con cada departamento o area del Distrito y completar los
documentos necesarios para asegurar que los estudiantes con alergias tengan los servicios necesarios.
LA so ORMA00t4
(RUKINEABILDAD DEL DISTRt10)
asot.r.AR
SAN MARCOS UNIFIED SCHOOL DISTRICT
CHILD NUTRITION SERVICES FOR KINDERGARTNERS
San Marcos Unified School District provides meals for kindergarten students every day including field
trips. Your student can begin their school day with a nutritious meal and be ready to learn. Breakfast
and Lunch service times and locations vary at each school site. These meals may be served in the
cafeteria. Please confirm this information with your student's teacher or cafeteria site manager.
If you would like your child to be qualified for free or reduced price meals on the first day of school,
you must pick up an application for free or reduced price meals after August 1, 2014 at the District
Office. Complete the application and return it to the school or District Office no later than August 13,
2014. If you have other students in the District who are currently qualified for free or reduced price
meals, these students must also be included on the 2014-2015 meal application. If you have any
questions call Rose Howell at 752-1253.
For the 2014-2015 school year, the prices for meals and beverages will be:
Kindergarten Breakfast
Kindergarten lunch
$1.25/day
$2.25/day
Meals can be pre-paid using our online system (myschoolbucks.com ) or a yellow prepayment
envelope at the school. Prepayments are placed on an account and money will be deducted from the
student's account when a meal is served.
Milk a la carte price
Juice, 4oz., a la carte price
$0.50
$0.50
Breakfast and lunches are also available at a reduced price and free of charge for those who qualify.
Kindergarten breakfast reduced price
Kindergarten lunch reduced price
Kindergarten breakfast/lunch free
$0.25/day
$0.40/day
$0.00/day
Reduced price meals may be purchased daily or by prepayment. Accounts will be kept in the same
manner as the paid accounts above.
Please mark your calendar on the date of August 1, 2014, if you need to pick up an application for
free or reduced price meals. Call Rose Howell at 760-752-1253 if you have questions or speak with
the cafeteria staff at your child's school. We look forward to serving your child next year.
In accordance with Federal law and U. S. Department of Agriculture (USDA) and the California Department of Education (CDE). To file a complaint of
discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 14th and Independence Avenue, SW, Washington, DC 202509410 or call (202) 720-5964 (voice and TDD). The USDA, CDE and NSD are equal opportunity providers and employers
12/17/2013
DISTRITO ESCOLAR UNIFICADO DE SAN MARCOS
SERVICIOS DE NUTRICIoN PARA ALUMNOS DE KINDER
El Distrito Escolar Unificado de San Marcos le ofrece comidas todos los dias a los alumnos de Kinder,
incluyendo cuando hay excursiones escolares. Su estudiante puede comenzar el dia escolar con una comida
nutritiva. Las horas del desayuno y el almuerzo varian por escuela. Cada mes los estudiantes tendren
disponible un menu para Ilevar a casa. Por favor confirme el horario con las maestras.
Si a usted le gustaria que su hijo calificara para recibir comidas gratuitas o a precio reducido el primer dia de
clases, recoje un solicitud a partir del 1 de augusto de 2014 en las oficinas del Distrito. Complete la solicitud
y regresela antes del 13 de agosto de 2014 a las oficinas del Distrito. Si usted tiene hijos(as) en el Distrito que
ya hayan calificado para comida gratis o con precio reducido inclUyalos en la solicitud del ario escolar 20142015. Si tiene cualquier pregunta no dude en Ilamar al 760-752-1253.
Los precios de la comida y las bebidas para el ano escolar 2014-2015 seran los siguientes:
Desayuno de Kinder
Almuerzo de Kinder
$1.25/ por dia
$2.25/ por dia
La comida se puede pagar por medio de nuestro sistema en linea (myschoolbucks.com ) o con un pre pago por
medio del sobre amarillo. Los prepagos son acreditados en la cuenta del estudiante y el dinero sera deducido
de la cuenta del estudiante cuando una comida sea servida.
Leche a la carta
Jugo, 4oz, a la carta
$0.50
$0.50
El desayuno y los almuerzos estan disponibles a precio reducido y gratis para los alumnos que califican.
Precio reducido de desayuno de Kinder
Precio reducido del almuerzo de Kinder
Almuerzo gratis de Kinder
$0.25/dia
$0.40/dia
$0.00/dia
La comida con precio reducido tambien se puede pagar diariamente o con pre pago. Las cuentas seran
manejadas de la misma manera que como as cuentas que se mencionan arriba. Por favor marque su
calendario para el 1 de agusto de 2014 si es que quiere recoger una solicitud para comida gratis o con precio
reducido. Si tiene cualquier pregunta (lame a Rose Howell al 760-752-1253 o tambien se puede comunicar con
el personal de la cafeteria en la escuela de su hijo(a). Estamos felices de poder servirle a su hijo(a) el
siguiente ario escolar.
C. 20250-9410, o !lame al (202) 720-5964 (voz y TDD). USDA, NSD y el CDE son proveedores y empleadoes que ofrecen oportunidad De acuerdo a lo
establecido por as !eyes Federales y El Departamento de Agricultra de los EE. UU. (USDA; siglas en ingles) y el Departamento de EducaciOn de
California (CDE) Para presentar una queja sobre discriminacion, escriba a USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400
Independence Avenue, SW, Washington, D. igual a todos.
Revised 2/7/11