______________________________________________________________________________

*NEW STUDENT (NON - EGUSD) REGISTRATION DOCUMENTS CHECKLIST

In order to complete the registration and enrollment process, you will need to provide the items listed below with your registration packet.

Timeline January EGVA Open Enrollment for Fall Semester begins at Las Flores High School 5900

Bamford Drive, Sacramento, CA 95823

March 1 Last day EGVA Open Enrollment for current Spring Semester at Las Flores High School 5900 Bamford Drive, Sacramento, CA 95823

* Registration paperwork accepted M – F, 8:00 A.M. – 3:30 P.M. at the address listed above

Item Description Documentation required for Registration Personal documents needed to register EGUSD Student Registration Forms Complete the entire packet of documents Emergency Information Form Required form for emergency contacts Master Agreement Form Mandatory form signed by both parent and student Birth Certificate Copy of original Immunization Record Copy of the most current record Legal Guardian’s Identification Driver’s License/Passport/State ID with correct/current address Proof of Residency Please see acceptable/required POR list

INTER District Transfer Form (Not Included)

*Please obtain from current school district of residence

Additional Items due within 30 days of start date

Description

Technology Use Form Complete this form, sign and return Technology Terms of Participation

Form Complete this form, sign and return

Health Information Form Used to record any health issues Special Services Survey Form Used to acknowledge special services your student has received

in the past Indian Education Form Student eligibility certification if needed Parent/Student Expectation Forms Read, sign and date to ensure understanding Opt-Out Form (OPTIONAL) OPTIONAL Return form only if you wish to opt out of one or all

areas listed on the opt-out form. *Student NOT residing within the Elk Grove Unified School District boundaries will need an INTER District Transfer Form.

Elk Grove Unified School District Virtual Academy

5900 Bamford Drive Sacramento, CA 95823

916-399-9890

Elk Grove Unified School District – Excellence by Design

To whom it may concern:

The following documents are required to register your child:

• Birth Certificate

• Immunization record

• Proof of residence within the district*

• All students entering 7th grade will need to provide proof that they have received an adolescent pertussis (whooping cough) booster shot (Tdap) prior to starting school.

* Residence Documents Required for Initial Enrollment for all K-12 Students: Must produce ONE of the following for enrollment:

• Property tax receipts for the current residence

• Mortgage statements in parent/guardian name. If the home is under construction a title/deed or signed sales or purchase agreement in parent/guardian’s name will be accepted. A current PG&E, SMUD bill that indicates location of service, or a mortgage payment must be presented to the school within six months

• Rental/Lease agreement – current or recently signed in parent/guardian name. Additionally, two consecutive months of a current PG&E or SMUD bill in the parent/guardian name must be presented to the school within two months

AND

Must also produce ONE of the following for enrollment:

• Parent/guardian’s motor vehicle registration with current residence

• Parent/guardian’s driver’s license with current residence

• Court documents indicating current residence

• Payment verification (paid invoice, credit card receipt, cashed check) for 2 consecutive months of 2 of the following utilities: gas, electricity, water, or garbage for the current residence must be presented within 2 months of enrollment

• Rent payment receipts for 2 consecutive months for the current residence must be presented within 2 months of enrollment

• Documentation from the Department of Human Assistance with current residence

Members of the School Board Beth Albiani Nancy Chaires Espinoza Carmine S. Forcina Chet Madison, Sr. Dr. Crystal Martinez-Alire Anthony “Tony” Perez Bobbie Singh–Allen

Las Flores High School Alan Williams Administrator

(916) 422-5604

Fax: (916) 428-8307 allwilli@egusd.net

Las Flores High School 5900 Bamford Drive * Sacramento, CA 95823

STUDENT REGISTRATION TODAY’S DATE ____/____/____ PLEASE PRINT *Has the student ever been enrolled in an Elk Grove Unified School District school? Y / N *Is this student currently expelled or pending an expulsion hearing in EGUSD or any other district? Y / N ________________________________________ __________________________ _______________ ________SSN ______-______-______ *Student’s Legal Last Name *First Name Middle Name (Suffix: Jr. Sr.)

______________________ _____________________ _____________ _______________________________ ___________ (Nick Name) AKA First Name AKA Middle Name AKA Last Name AKA Suffix *Student’s Home Telephone ______ - ______ - ________ Phone Unlisted? Y / N *Grade Level: ________ *Gender: Male / Female (Area Code)

*Birth Date _____/______/_______ *Birthplace ____________________________ _______ ______________________________ MM / DD / YYYY (City) (State) (Country)

Foreign Born United States Citizen? Y / N If Foreign Born, does student have three years of cumulative enrollment in the United States? Y / N *What special services has your child received? Check all that apply: Special Ed. Program? GATE? 504? ESL/Bilingual? *What is your child’s Ethnicity? (Please check one) Hispanic or Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race) Not Hispanic or Latino *What is your child’s Race? (Please show one or more) The question above is about ethnicity, not race. No matter what you selected above, please select a race that best represents your heritage for group data by selecting one or more of the races located in the Race Codes chart on page 4. Race codes #_______,#______, #______, #______, #______ HOME LANGUAGE SURVEY (Questions for “new” student registration only) *Which language did your son or daughter learn when he or she first began to talk? __________________________________ *What language does your son or daughter most frequently use at home? ___________________________________________ *What language do you use most frequently to speak to your son or daughter? _______________________________________ *Name the language most often spoken by the adults in the home: _________________________________________________ *Residence _____________ ______________________________________________ ________ _______________________ ______ ___________ Address (Street Number) (Street Name) (Apt#) (City) (State) (Zip Code) Address Unlisted? Y / N *Mailing Same as residence? Y / N If no ___________ ___________________________ ______ _______________________ ______ __________ Address (Street Number) (Street Name) (Apt#) (City) (State) (Zip Code)

*Is student currently: Foster Youth? Homeless? If Foster Youth, where is your child/family currently living? If Homeless, where is your child/family currently living? (Please check only one of the following) (Please check only one of the following) Foster Family Home or Kinship Placement (210) Temporary Shelter (100) Licensed Children’s Institution (Group Home) (220) Hotels/Motel (110) Temporarily Doubled Up (120)

Temporarily Unsheltered (130)

**FOR OFFICE USE ONLY** EGUSD Student Number____________________ Birth Date Verified Enrollment Permit Code_____________________

School Enrollment Date____/____/______ Birthplace Verified Enrollment Permit Reason____________________________________

School Name______________________________ Legal Name Verified Immunizations Complete? Y / N

Address Verification Method_________________ Date Birth Info Verified____/____/______ Parent Highest Ed Level (see pg 2 & 3) __________________

Date Address Verified____/____/______ Birth Place Verification Method________________

Track Restrictions? Y / N Primary Language (see pg 4 chart)

Enrolled by_______________________________ Date entered_____/_____/______

PAGE 2 STUDENT ENROLLMENT INFORMATION continued DAY CARE INFORMATION (Applies to Elementary/Middle School Students Only)

Day Care ______________________________Cell Phone ______ - ______ - _______ Home Phone ______ - ______ - _______ Work Phone ______ - ______ - _______ Provider Name (Area Code) (Area Code) (Area Code)

Day Care ____________ _________________________________________ ______ _______________________ ______ _________ Address (Street Number) (Street Name) (Apt#) (City) (State) (Zip Code)

*LAST SCHOOL ATTENDED _______________________________________________________________ Phone#_______ - _______ - _______ (School Name) (Area Code)

School Address __________ _________________________________________________ ____________________________ ______ __________ (Street Number) (Street Name) (City) (State) (Zip Code)

STUDENT MISC INFORMATION (Questions for “new” student registration only)

*What month, day and year did your child first enroll in the U. S. school system not including Preschool? _____/_____/________ MM / DD / YYYY

*What month, day and year did your child enter (or enroll) in a California Public School? _____/_____/_______ MM / DD / YYYY Did your child attend preschool (for at least 6 months) immediately prior to enrolling in Kindergarten? Yes / No If yes, please check the type of Preschool Program: Elk Grove Unified School District-Preschool Program (Head Start, Title 1, State Preschool) Other public Preschool outside EGUSD – Name of Program ___________________________________________ Partners Preschool through EGUSD Adult Education Private Preschool

DOES YOUR STUDENT HAVE ACCESS TO THE INTERNET FROM HOME? Yes / No

LEGAL PARENT/GUARDIAN INFORMATION (1) *Legal Guardian Relationship to student _________________________ *Live with student? Y / N Do you wish to receive school mailings? Y / N Do you wish to participate in EGUSD Portal in lieu of certain mailings? Y / N

______________________________ _____________________ _____________ ___________ *Guardian’s Last Name *First Name Middle Initial (Suffix: Jr. Sr.)

* Guardian ____________ _________________________________________ ______ _______________________ ______ _________ Address (Street Number) (Street Name) (Apt#) (City) (State) (Zip Code)

* Guardian’s Home Phone#_______ - _______ - _______ Cell Phone#_______ - _______ - _______ Pager/Cell#_______ - _______ - _______ (Area Code) (Area Code) (Area Code)

Email Address _____________________________________________________________________________________________ PARENT/GUARDIAN MISC INFO (1)

Primary Language ________________(see page 4 chart) Language assistance needed? Y/N Driver’s License # __________________State ______

Name of Employer __________________________________________ Employer Phone#_______ - _______ - _______ _______ (Area Code) (Ext)

* PARENT/GUARDIAN EDUCATIONAL LEVEL (Check the response that describes parent/guardian (1) education level)

College Graduate Graduate Degree or Higher High School Graduate Not a High School Graduate Some College or Associate’s Degree

PAGE 3 STUDENT ENROLLMENT INFORMATION continued LEGAL PARENT/GUARDIAN INFORMATION (2) *Legal Guardian Relationship to student _________________________ *Live with student? Y / N Do you wish to receive school mailings? Y / N Do you wish to participate in EGUSD Portal in lieu of certain mailings? Y / N ______________________________ _____________________ _____________ ___________ *Guardian’s Last Name *First Name Middle Initial (Suffix: Jr. Sr.)

* Guardian ____________ _________________________________________ ______ _______________________ ______ _________ Address (Street Number) (Street Name) (Apt#) (City) (State) (Zip Code)

* Guardian’s Home Phone#_______ - _______ - _______ Cell Phone#_______ - _______ - _______ Pager/Cell#_______ - _______ - _______ (Area Code) (Area Code) (Area Code)

Email Address _____________________________________________________________________________________________ PARENT/GUARDIAN MISC INFO (2)

Primary Language ________________(see page 4 chart) Language assistance needed? Y/N Driver’s License # __________________State ______

Name of Employer __________________________________________ Employer Phone#_______ - _______ - _______ _______ (Area Code) (Ext) * PARENT/GUARDIAN EDUCATIONAL LEVEL (Check the response that describes parent/guardian (2) education level)

College Graduate Graduate Degree or Higher High School Graduate Not a High School Graduate Some College or Associate’s Degree

*EMERGENCY CONTACT (Other than Legal Parent/Guardian to child) If I cannot be reached, I authorize the school to call, release my child to, or take my child to the following individual(s). This consent is effective until revoked in writing. *Initial here ______ 1. Relationship to Child _____________________________ ________________________ ____________________ _____________ __________ *Last Name *First Name Middle Initial (Suffix: Jr. Sr.)

Cell Phone#_______ - _______ - _______ Home Phone#_______ - _______ - _______ Work Phone#_______ - _______ - _______ _______ (Area Code) (Area Code) (Area Code) (Ext) 2. Relationship to Child ___________________________ _________________________ _____________________ _____________ ___________ *Last Name *First Name Middle Initial (Suffix: Jr. Sr.

Cell Phone#_______ - _______ - _______ Home Phone#_______ - _______ - _______ Work Phone#_______ - _______ - _______ _______ (Area Code) (Area Code) (Area Code) (Ext)

OTHER CONTACT

_______________________________________ Phone#_______ - _______ - _______ ____________________________________ Phone#_______ - _______ - _______ Social Worker/Case Worker Name (Area Code) Probation Officer Name (Area Code)

MEDICAL INFORMATION

Name of Insured ______________________________ _____________________ _____________ ___________ Last Name First Name Middle Initial (Suffix: Jr. Sr.)

Name of Health Insurance ____________________________ Medical ID#/Policy# ________________________ Phone#_______ - _______ - _______ (Area Code)

___________________________________ Phone#_____ - _____ - _______ _________________________________ Phone#_____ - _____ - _______ Doctor’s Name (Area Code) Hospital’s Name (Area Code)

SPECIAL HEALTH ISSUES

________________________________________ ____________________________________________ _________________________________________________ Allergies Medical Problems/Chronic Illness Other Comments/Information

In an emergency, when I cannot be reached, I authorize the school authorities to take my student, at my expense, to my family doctor, licensed physician, nearest hospital or emergency first-aid station for treatment. This consent is effective until revoked in writing. *Initial here ______Yes, I do give permission for treatment OR *Initial here ______No, I do not give permission for treatment

PAGE 4 SIBLING INFORMATION, PRIMARY RACE CODES & PRIMARY LANGUAGE CODE CHARTS SIBLING INFORMATION

I affirm, to the best of my knowledge, that the above information is correct and that I will notify the school each time there is a change in any of this information. ______________________________________________________________________Date____/____/____ *Signature *Race Codes

American Indian or Alaskan Native(100) (Persons having origins in any of the original peoples of North, Central or South America )

Chinese (201) Japanese (202) Korean (203) Vietnamese (204) Asian Indian (205)

Laotian (206) Cambodian (207) Hmong (208) Other Asian (299) Hawaiian (301) Guamanian (302) Samoan (303)

Tahitian (304) Other Pacific Islander (399) Filipino/Filipino American (400) African American or Black (600) White (700) (Persons having origins in any of the

original peoples of Europe, North Africa, or the Middle East)

Primary Language Codes Language Code Language Code Language Code Language Code

Albanian 56 French 17 Kurdish 51 Somali 60 American Sign Language

37 German 18 Lahu 47 Spanish 01

Arabic 11 Greek 19 Lao 10 Taiwanese 46 Armenian 12 Gujarati 43 Mandarin

(Putonghua) 07 Tamil 63

Assyrian 42 Hebrew 21 Marathi 64 Telugu 62 Bengali 61 Hindi 22 Marshallese 48 Thai 32 Burmese 13 Hmong 23 Mien(Yao) 44 Tigrinya 57 Cantonese 03 Hungarian 24 Mixtexo 49 Toishanese 53 Cebuano (Visayan) 36 Ilocano 25 Pashto 40 Tongan 34 Chaldean 54 Indonesian 26 Polish 41 Turkish 33 Chamorro (Guamanian)

20 Italian 27 Portuguese 06 Ukrainian 38

Chaozhou (Chaochow)

39 Japanese 08 Punjabi 28 Urdu 35

Dutch 15 Kannada 65 Rumanian 45 Vietnamese 02 English 00 Khmer

(Cambodian) 09 Russian 29 All Other Non-

English 99

Farsi (Persian) 16 Khmu 50 Samoan 30 Filipino (Tagalog) 05 Korean 04 Serbo-Croatian

(Bosnian) 52

Last Name First Name Birthday ( MO/ DAY/ YR)

Gender ( M / F)

Track School Grade Level

PAGE 5 PRIMARY RESIDENCE CODE CHART

*Primary Residence Codes (Federally mandated by NCLB) Temporary Shelters 100 A temporary residence provided for homeless individuals who would otherwise sleep on the

street or a temporary residence provided to individuals in emergency situations. This is also applicable to children who are in temporary residences awaiting permanent placement in foster care.

Hotels/Motels 110 A temporary residence for homeless individuals usually requiring payment or vouchers for lodging and services on a daily, weekly, or monthly basis.

Temporarily Doubled Up 120 A temporary residence where a homeless family is sharing the housing of other persons due to the loss of housing, economic hardship, or other similar reasons.

Temporarily Unsheltered 130 A type of residence for homeless individuals that is not meant for human habitation, such as cars, parks, sidewalks, abandoned buildings, campgrounds, trailer parks, bus and train stations, or persons abandoned in the hospital (on the street). A rule of thumb would be to see the dwelling as comparable to an automobile in that it shelters but is not adequate housing.

Permanent Housing 200 A type of fixed and regular residence that is owned, rented, or sublet. Foster Family Home or Kinship Placement

210 A family residence that is licensed by the state, or other public agency having delegated authority by contract with the state to license, to provide 24-hour non-medical care and supervision for not more than six foster children, including, but not limited to, individuals with exceptional needs. This also includes “Small Family Homes” as described in Health and Safety Code Section 1502(c) (6) (Education Code Section 56155.5[b]), or an “Approved Home” of a relative. An “Approved Home” means the home of a relative or non-relative extended family member that is exempt from licensure and is approved as meeting the same standards as those set forth in CCR Title 22, Div.6, Article 3. This is not the same as a Licensed Children’s Home.

Licensed Children’s Institution 220 A residential facility that is licensed by the state, or other public agency having delegated authority by contract with the state to license, to provide non-medical care to children, including, but not limited to, individuals with exceptional needs. Licensed children’s institution includes a group home as defined by subdivision (g) of Section 80001 of Title 22 of the California Code of Regulations. As used in this article and Article 3 (commencing with Section 56836.16) of Chapter 7.2, a “licensed children’s institution” does not include any of the following: (1)A juvenile court school, juvenile hall, juvenile home, day center, juvenile ranch, or juvenile camp administered pursuant to Article 2.5 (commencing with Section 48645) of Chapter 4 of Part 27. (2)A county community school program provided pursuant to Section 1981. (3)Any special education programs provided pursuant to Section 56150. (4)Any other public agency.

Residential School/Dormitory 230 A nonsectarian school where a student with exceptional needs resides on a 24-hour basis and receives special education and related services at the school. This includes both public and private facilities. This is not the same as an Incarceration Institution or a Licensed Children’s Institution.

Health Institution 240 A public hospital, state licensed children’s hospital, psychiatric hospital, proprietary hospital, or a health facility for medical purposes. (E.C 56167(a)). It does not state hospitals operated by the California Department of Developmental Services.

Incarceration Institution 250 Individuals who have been adjudicated by the juvenile court, for placement in a juvenile hall or juvenile home, day center, ranch, or camp, or for individuals placed in a county community school (E. C. 56150); includes placement in the Department of Corrections – Division of Juvenile Justice (formerly California Education Authority or California Youth Authority), and other public correctional institutions.

Development Center 260 A residential facility providing services to individuals who have been determined by the Department of Developmental Services (DDS) regional centers to require programs, training, care, treatment and supervision in a structured health facility setting on a 24-hour basis. This is not the same as Residential School/Dormitory, Health Institution, or State Hospital.

State Hospital 270 A state hospital is a residential facility operated by the California Department of Mental Health (DMH). This is not the same as Residential School/Dormitory, Health Institution, or Development Center.

Other 300 Any other type of residence not referenced in any other Primary Residence Category.

Unknown 310 The primary residence of an individual cannot be determined. For example, the information is unavailable or was erroneously reported and is indecipherable.

09 – Emergency Information EMERGENCY INFORMATION (REQUIRED)* ELK GROVE UNIFIED SCHOOL DISTRICT Name Sex: F M Last First Middle Legal last name (if different) Birthdate: Home Phone: Address Apt. City Zip List below parent(s) or guardian child lives with: Relationship Home Phone: Name: to Child: Employer: Work Phone: Relationship Home Phone: Name: to Child: Employer: Work Phone: If parents are divorced or separated, who has physical custody? Parents should notify the district immediately if there is a change. Joint Custody Mother Father Guardian Day Care: Name Phone In case of illness, emergency or accident and parent/guardian cannot be located, the following adults are authorized to act on behalf of the parent/guardian. (Please enter two names of local neighbors, friends, relatives, or sitter.) 1. Phone Relationship 2. Phone Relationship Physician’s Name Medical Coverage by ID# Address Physician Phone # Hospital of Preference

1. In the event of an emergency, when a parent or guardian is unavailable, I authorize school personnel to make arrangements for my child to receive medical//hospital care, including necessary transportation, in accordance with their best judgment. I authorize the physician named above to undertake such care and treatment as is considered necessary. In the event said physician is unavailable, I authorize such care and treatment to be performed by a licensed physician or surgeon. I agree to pay all costs incurred as a result of the foregoing. 2. I do not choose the above statement and desire the following action in the event of an emergency: . I understand that the Elk Grove Unified School District does not provide medical insurance for student injuries, but does make voluntary student insurance available. I have received the information on this program.

X X Parent/Guardian’s Signature Date Parent/Guardian’s Signature Date

PLEASE CHECK THE FOLLOWING ITEMS IF THEY PERTAIN TO YOUR CHILD

School Track Grade Room Teacher/Counselor Bus # Bus Stop Student Number

PARENT MUST

CHECK ONE

GENERAL HEALTH 1. Has the following condition(s):

Epilepsy Fainting spells Diabetes Hyperactive (ADHD) Heart condition Migraines Asthma Allergies (describe): Allergic reaction to bee stings (describe): Other: Are any of the above life threatening? Yes No Please Explain

2. List medication(s) prescribed:

Current dosage: For (diagnosis): Does the drug need to be taken during school hours? Yes No Prescribed by Dr. Ph.

3. Has a physical condition which limits participation in:

classroom activities physical education Please explain: Under care of Dr. Ph. 4. DATE OF LAST TETANUS SHOT

CHECK HERE IF THERE ARE NO KNOWN HEALTH PROBLEMS EYES Wears glasses To be worn at all times Wears contacts To be worn at all times Requires preferential seating Date of last eye exam: Under care of Dr. Phone Comments: EARS Has a hearing problem Has tubes in ears Uses hearing aid Requires preferential seating Under care of Dr. Phone Comments: BROTHERS & SISTERS SCHOOL OF NAME(s) ATTENDANCE GRADE 1. 2. 3. *California Education Code 49408 requires that emergency information be kept current. **The parent or legal guardian of a public school pupil on a continuing medication regimen for a nonepisodic condition (pupils taking medication on a long-term regular schedule) shall inform the school nurse or other designated certificated employee of the medication being taken. (California Ed Code 49480) ***The California Education Code makes it mandatory that every student be provided with physical education. If, at any time you child is ill or has a condition which you feel requires being excused from activity for more than five (5) school days, an explanatory note is required from your child’s health advisor.

ELK GROVE UNIFIED SCHOOL DISTRICT

Virtual Academy 5900 Bamford Drive Sacramento, CA 95823 (916) 399-9890

OFFICE USE ONLY: Teacher___________________

VIRTUAL ACADEMY MASTER AGREEMENT FOR K-8 • Supplemented by Course Assignment and Work Record Forms

STUDENT ID # NAME (last, first, mi)

ADDRESS

GRADE

CITY ZIP AGE

PHONE # WORK # BIRTHDATE

ENTRY DATE

EXIT DATE LOCATION

OBJECTIVES: The student will attempt to complete the courses listed below during the trimester as are outlined in the Elk Grove Virtual Academy course descriptions. 1. All course objectives will be consistent with the guidelines established by the Elk Grove Unified School District curriculum. Assignment and work forms include additional descriptions of the major objectives and activities of the course of study covered by the agreement, as well as the methods for evaluating the course work. 2. The Elk Grove Unified School District will provide the teacher services, instructional material and other necessary items and resources as specified for each assignment. 3. The student and parent agree to meet with or report to the teacher regularly according to the frequency, date, time and location specified in the assignment and work record form. Each assignment and work record form is incorporated in and made a part of this agreement. 4. According to district policy BP6158.(b) for independent study, no more than 1 week for K-3, and 2 weeks for grades 4-8 may elapse between the date an assignment is made by the teacher and the date it is due.

CERTIFICATION: Report card or transcript.

*SUBJECT COURSE VALUE *SUBJECT COURSE VALUE

SIGNATURES: We have read this agreement (back page) and hereby agree to all the conditions set forth within.

Student___________________________________ Parent/Guardian __________________________________ (Date) (If student is under age 18) (Date) Teacher Teacher _____ (Date) (Date)

Teacher___________________________________ Other __________________________________________ (Date) (Date)

Page 1

K-8 VIRTUAL ACADEMY MASTER AGREEMENT (Continued)

S T U D E N T: I understand that: • Virtual Academy is an optional education alternative that I have voluntarily selected. • By enrolling in the Virtual Academy, I have not waived any rights as a student, and I am entitled to all Elk Grove Unified School

District services and resources. If I’m a student with an individualized education program (I.E.P.), it must specifically provide for my enrollment in Virtual Academy.

• I must follow the discipline code and behavior guidelines of the Elk Grove Unified School District. Any violation of these guidelines or failure to meet school/district requirements could result in dismissal from the Virtual Academy.

• Visitation on any other school campus requires permission from that school. • Students in grades K-6 will earn a passing grade in Reading/Language Arts, Writing, Math, Spelling, Social Studies, Science and

P.E. I agree to: • Be supervised by a Virtual Academy teacher and/or other approved resource personnel. • Meet or report regularly with assigned teacher and/or supervisor, and I understand that my parent/guardian must also attend the

meeting. The frequency, date, time and location will be determined by my work assignments. I realize that it is my responsibility to promptly reschedule any appointment missed due to any emergency, and that failure to report to an appointment and/or failure to submit evidence of completed assignments could result in one or more of the following:

1. A letter of concern to me and my parent, if appropriate. 2. A specially scheduled school appointment. 3. A meeting with the teacher and/or counselor. 4. A meeting with the administrator, including parent or guardian, if appropriate. 5. Placement on probation. 6. Termination of the agreement and my return to a regular classroom of instruction or other appropriate alternative

• Obtain transportation to scheduled meetings. I understand that lack of transportation to the school site is not an acceptable reason for failing to meet with my teacher and/or supervisor to submit my completed assignments.

• Attend all state and district mandated tests as scheduled. • In order to complete my school requirements, consistent with the traditional school, I need to complete more than the minimum

study requirements. I must complete my assigned work and achieve at least the minimum performance requirements of the course of study. I understand that grades and/or credit, which are based on mastery of learning, can only be issued after I have successfully completed an activity and it has been evaluated.

• I am liable for the cost of replacement or repair for damaged or lost books and other materials that are checked out to me. P A R E N T: I understand that: • The major objective of the Virtual Academy is to provide a voluntary educational alternative for my son/daughter. I agree to the

above conditions listed under STUDENT. I also understand that: • Individual course objectives are consistent with and evaluated in the same manner they would be if my son/daughter were

enrolled in a traditional school program. • I am liable for the cost of replacement or repair for damaged or lost books and other materials that are checked out to my

son/daughter. • Unless otherwise indicated, a teacher or supervisor will meet/communicate with me and my son/daughter on a regular basis to

direct and measure progress. The time and location of meetings with the teacher or supervisor will be determined by the teacher or supervisor in consultation with me and my son/daughter.

• It is my responsibility to provide transportation to the school site for my son/daughter when required and for all state and district mandated tests as scheduled.

• I have the right to appeal any decision about my son/daughter’s placement, school program or transfer, according to Elk Grove Unified School District’s procedures.

Page 2 (Revised 2/12)

EGUSD Use of Technology in Instruction

Application for Educational Use of the Internet

Elk Grove Unified School District provides limited access to the Internet, which includes

local, national and international sources of information via its local network. Every

EGUSD user has the responsibility to respect and protect the rights of every other user in

our community and on the Internet. Student account holders are expected to act in a

responsible, ethical and legal manner on the Internet. Students are taught network

etiquette and are expected to follow it. To become a user, students and their parents must

complete this form and return it to their school.

Students using these systems are subject to having all activities, including e-mail,

monitored by system or security personnel. EGUSD has taken all reasonable steps to

ensure the Internet is used only for purposes consistent with the curriculum. The district

or school cannot prevent the availability of material elsewhere on the Internet that may be

deemed harmful or intended for adults, especially to someone determined to find it.

Information obtained via the Internet is at the user’s risk. Using the network is a

privilege, not a right, and a student’s privilege may be revoked at any time for

unacceptable conduct. Please read the information online at http://www.egusd.net/discover_EGUSD/pdfs/AR_6162_7.pdf

Your signature below gives your permission for your student to use the district’s network

and Internet access, and also confirms your understanding of the rules associated with the

network. You also understand that any user who breaches these guidelines may lose all

privileges on the network and/or be subject to appropriate disciplinary or legal actions.

(please print)

Student's Name: ______________________________________________________

Student Grade Level: ________________

Date: _______________________________________________________________

Home Address: _______________________________________________________

Student Signature: _____________________________________________________

Student Identification #: ________________________________________________

Parent/Guardian's Signature: _____________________________________________

Please return this form to your child’s school office.

EGUSD VIRTUAL ACADEMY Terms of Participation Agreement

The Elk Grove Virtual Academy (“EGVA”) is a unique learning opportunity for the 21st century

parent and student, offering online instruction for students in kindergarten through 8th grade.

EGVA is part of Elk Grove Unified School District (“District”), and enrollment in EGVA is

voluntary. The undersigned, __________________________ (“Parents”), as parents and legal

guardians of __________________________ (“Student”), and Student acknowledge, accept, and

agree that enrollment in EGVA is subject to the terms set forth below. Parents and Student must

both sign this Agreement before a Student’s enrollment. District may refuse enrollment for any

lawful reason.

1. EGVA Program

EGVA courses are offered online. Student will access EGVA courses over the Internet on a

schedule that is consistent with Student’s individualized learning program. Student’s primary

interaction with EGVA teachers will be online through EGVA’s secure, password-protected

website. Student shall post work to EGVA’s website and teachers will grade, score and provide

feedback on Student’s work through the website. Individual student grades will be

communicated to the Student and Parents via standard District procedures, and not through a

public forum. By signing below, you indicate that you understand the online nature of the

EGVA’s program.

2. Technology Used to Access EGVA Courses

Parents and Student are responsible for acquiring, installing and maintaining the computer

hardware and Internet connection used by Student in accessing EGVA’s courses. District

disclaims all liability for Parents’ and Student’s installation and operation of computer hardware

and Internet connections used to access EGVA’s courses. District does not install software on

computers supplied by the program that allows it to turn on webcams remotely, and District will

not monitor student use of such computers. District is not responsible for installing or

monitoring blocking software to control Student’s access to material on the Internet.

3. District Policies

District policies generally require teacher or administration authorization and Parents’ approval

before Student work can be posted online. By signing below, Parents give permission for all of

Student’s work in connection with EGVA courses to be posted online on the password-protected

secure website. Parents also consent to Student’s participation in video-conferencing with

EGVA teachers as necessary. Parents will monitor Student work and postings to ensure Student

complies with District policies and administrative regulations regarding use of technology.

Parents acknowledge that they have received a copy of District’s annual Parent & Student

handbook, which includes District’s policies and administrative regulations regarding use of

technology.

4. Acceptable Use

Use of the Internet and EGVA’s website is a privilege, not a right. Transmission of any material

on or through EGVA’s website in violation of any United States or California state law or

regulation is prohibited. This includes, but is not limited to, copyrighted material, threatening or

obscene material, or material protected by trade secret. Illegal activities are strictly prohibited.

Any inappropriate use of EGVA’s website may result in the cancellation of Student’s privileges,

discipline, and/or possible legal action. Parents will be held financially responsible for any harm

that may result from Student’s intentional misuse of EGVA’s website or District’s network.

5. Limitation of Liability

District does not guarantee that the functions or services provided through District network or on

EGVA’s website will be without error. District is not responsible for any damage Student may

suffer as a result of enrolling in EGVA and participating in courses over the Internet, including

but not limited to, loss of data, interruption of service, or exposure to inappropriate persons or to

material not provided by District or a District employee.

6. Waiver and Release

Parents, for ourselves and on behalf of Student, and Student, hereby release and hold harmless

Elk Grove Unified School District, its officers, officials, agents and/or employees, volunteers,

and other participants in EGVA, for any and all injury, loss or damage arising out of or in any

way related to Student’s participation in EGVA or use of District’s website and network.

I HAVE READ THE FOREGOING AGREEMENT, FULLY UNDERSTAND ITS TERMS

AND SIGN IT FREELY AND VOLUNTARILY. I UNDERSTAND THAT THIS

DOCUMENT HAS LEGAL CONSEQUENCES AND UNDERSTAND THAT I MAY HAVE

AN ATTORNEY REVIEW THIS DOCUMENT.

________________________________________ __________________________

Student Date

____________________

Student EGUSD ID#

________________________________________ __________________________

Parent Date

Revised 05/07/10

ELK GROVE UNIFIED SCHOOL DISTRICT

Office of Health Services

HEALTH INFORMATION

Date ___________________ Teacher________________________ Grade _________ School _________________

Name of Student _________________________________________________ Birthdate _____________________

Parent’s Name _________________________________________ Phone (______)________________________

Address ______________________________________________ City/State ________________________________

Family Dr. ______________________________________________________________________________________

(Name) (Phone)

Last School Attended ____________________________________________________________________________

MEDICAL HISTORY: Please mark an (X) if your child has had any of the following:

(If you need more room to explain, please use the back of this form)

_____ Diabetes _____ Chickenpox

_____ Epilepsy _____ German (3 day) Measles

_____ Heart Disease _____ Measles (Regular 10 days)

_____ Rheumatic Fever _____ Mumps

_____ Tuberculosis _____ Scarlet Fever

_____ Polio _____ Allergies - Explain

_____ Other (i.e. Nosebleeds)

Operation or Serious Injuries _____________________________________________________________________

Date of last physical exam _______________________ Name of Doctor or Agency ________________________

Have any special recommendations been made by your physician concerning the school life of this child?

Explain: ________________________________________________________________________________________

Has he/she ever worn glasses? ____________ Does he/she at this time? ________________________________

Has he/she ever had a hearing loss?________ If so, explain: ___________________________________________

Date of last dental exam _____________________ Name of dentist _____________________________________

Is your child currently on medication? __________ If so, explain ______________________________________

Signature of parent/guardian _____________________________________________________________________

03 – IZ Requirements and Health Information Form, Provided by Isabelle Aguiniga in Health Services, 05/07/10

SPECIAL SERVICES SURVEY

Student Name: Grade: Date of Birth: ____/____/____ Previous School or District: _____________________________________

1. Has your child ever been retained? If so, what grade? ______________ Yes No

2. Does your child have an active Individualized Education Plan/Program (IEP) developed pursuant to the Individuals with Disabilities Education Act (IDEA)?

Yes No

3. If you answered “Yes” to Question #2, does the IEP developed by your child’s current IEP Team provide for participation in Independent Study? (If you answer “Yes” to this question, please attach a copy of the IEP to this Special Services Survey)

Yes No

4. If you answered “Yes” to Question #3, have you provided written consent to the offer of placement in Independent Study? (If you answer “Yes” to this question, please attach a copy of the IEP to this Special Services Survey)

Yes No

5. Does your child have an active Section 504 Plan developed pursuant to Section 504 of the Rehabilitation Act of 1973?

Yes No

6. If you answered “Yes” to Question #5, does the Section 504 Plan developed by your child’s current Section 504 Team provide for participation in Independent Study? (If you answer “Yes” to this question, please attach a copy of the Section 504 Plan to this Special Services Survey)

Yes No

7. Has your child ever received Title 1 Services? Yes No

8. Has your child ever received Bilingual Services? Yes No

Which Language? __________________________

9. Has your child been “GATE identified”? Yes No

10. Do you have other children who have received special services? If yes, please explain what services.

Yes No

Child’s Name Grade School

11. Is there any special information you would like your child’s teacher to know regarding your child’s academic background or special needs?

To the best of my knowledge the information contained herein is true and factual. _____________________________________ _____________________ Parent/Guardian Signature Date

Elk Grove Unified School District Virtual Academy

5900 Bamford Drive Sacramento, CA 95823

(916) 399-9890

OMB Number: 1810-0021 Expiration Date: 07/31/2019

U.S. Department of Education Office of Indian Education

Washington, DC 20202 TITLE VI ED 506 INDIAN STUDENT ELIGIBILITY CERTIFICATION FORM

Parent/Guardian: This form serves as the official record of the eligibility determination for each individual child included in the student count. You are not required to complete or submit this form. However, if you choose not to submit a form, your child cannot be counted for funding under the program. This form should be kept on file and will not need to be completed every year. Where applicable, the information contained in this form may be released with your prior written consent or the prior written consent of an eligible student (aged 18 or over), or if otherwise authorized by law, if doing so would be permissible under the Family Educational Rights and Privacy Act, 20 U.S.C. § 1232g, and any applicable state or local confidentiality requirements.

STUDENT INFORMATION

Name of the Child __________________________________________________ Date of Birth ______________ Grade ______ (As shown on school enrollment records)

Name of School ____________________________________________________________________________________________ TRIBAL ENROLLMENT

Name of the individual with tribal enrollment: ___________________________________________________________________

(Individual named must be a descendent in the first or second generation)

The individual with tribal membership is the: _____ Child _____ Child's Parent _____ Child's Grandparent

Name of tribe or band for which individual above claims membership: _______________________________________________ The Tribe or Band is (select only one):

_____ Federally Recognized _____ State Recognized _____ Terminated Tribe (Documentation required. Must attach to form) _____ Member of an organized Indian group that received a grant under the Indian Education Act of 1988 as it was in effect October 19, 1994. (Documentation required. Must attach to form)

Proof of enrollment in tribe or band listed above, as defined by tribe or band is:

A. Membership or enrollment number (if readily available) _____________________________________________________ OR B. Other Evidence of Membership in the tribe listed above (describe and attach) _______________________________________ Name and address of tribe or band maintaining enrollment data for the individual listed above:

Name ____________________________________________ Address ________________________________________________ City _______________________________State ______Zip Code ____________ ATTESTATION STATEMENT I verify that the information provided above is accurate.

Name Parent/Guardian ______________________________________ Signature _______________________________________

Address ______________________________________ City ____________________________State ______Zip Code __________ Email Address ________________________________________ Date _______________

OMB Number: 1810-0021 Expiration Date: 07/31/2019

INSTRUCTIONS FOR THE ED 506 FORM

FOR APPLICANTS:

PURPOSE: To comply with the requirements in 20 USC 7427(a), which provides that: “The Secretary shall require that, as part of an application for a grant under this subpart, each applicant shall maintain a file, with respect to each Indian child for whom the local educational agency provides a free public education, that contains a form that sets forth information establishing the status of the child as an Indian child eligible for assistance under this subpart, and that otherwise meets the requirements of subsection (b)”. MAINTENANCE: A separate ED 506 form is required for each Indian child that was enrolled during the count period. A new ED 506 form does NOT have to be completed each year. All documentation must be maintained in a manner that allows the LEA to be able to discern, for any given year, which students were enrolled in the LEA’s school(s) and counted during the count period indicated in the application.

FOR PARENTS/GUARDIANS:

DEFINITION: Indian means an individual who is (1) A member of an Indian tribe or band, as membership is defined by the Indian tribe or band, including any tribe or band terminated since 1940, and any tribe or band recognized by the State in which the tribe or band resides; (2) A descendant of a parent or grandparent who meets the requirements described in paragraph (1) of this definition; (3) Considered by the Secretary of the Interior to be an Indian for any purpose; (4) An Eskimo, Aleut, or other Alaska Native; or (5) A member of an organized Indian group that received a grant under the Indian Education Act of 1988 as it was in effect on October 19, 1994. STUDENT INFORMATION: Write the name of the child, date of birth and school name and grade level. TRIBAL ENROLLMENT INFORMATION: Write the name of the individual with the tribal membership. Only one name is needed for this section, even though multiple persons may have tribal membership. Select only one name: either the child, child’s parent or grandparent, for whom you can provide membership information. Write the name of the tribe or band of Indians to which the child claims membership. The name does not need to be the official name as it appears exactly on the Department of Interior’s list of federally-recognized tribes, but the name must be recognizable and be of sufficient detail to permit verification of the eligibility of the tribe. Check only one box indicated whether it is a Federally Recognized, State Recognized, Terminated Tribe or Organized Indian Group. If Terminated Tribe or Organized Indian Group is elected, additional documentation is required and must be attached to this form.

Federally Recognized- an American Indian or Alaska Native tribal entity limited to those indigenous to the U.S. The Department of Interior maintains a list of federally-recognized tribes, which OIE can provide you upon request.

State Recognized- an American Indian or Alaska Native tribal entity that has recognized status by a State. The U.S. Department of Education does not maintain a master list. It is recommended that you use official state websites only.

Terminated Tribe-a tribal entity that once had a federally recognized status from the United States Department of Interior and had that designation terminated.

Organized Indian Group- Member of an organized Indian group that received a grant under the Indian Education Act of 1988 as it was in effect October 19, 1994.

Write the enrollment number establishing the membership of the child, if readily available, or other evidence of membership. If the child is not a member of the tribe and the child’s eligibility is through a parent or grandparent, either write the enrollment number of the parent or grandparent, or provide other proof of membership. Some examples of other proof of membership may include: affidavit from tribe, CDIB card or birth certificate. Write the name and address of the organization that maintains updated and accurate membership data for such tribe or band of Indians. ATTESTATION STATEMENT: Provide the name, address and email of the parent or guardian of the child. The signature of the parent or guardian of the child verifies the accuracy of the information supplied.

The Department of Education will safeguard personal privacy in its collection, maintenance, use and dissemination of information about individuals and make such information available to the individual in accordance with the requirements of the Privacy Act.

PAPERWORK BURDEN STATEMENT According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of

information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1810-0021.

The time required to complete this portion of the information collection per type of respondent is estimated to average: 15 minutes per Indian

student certification (ED 506) form; including the time to review instructions, search existing data resources, gather the data needed, and complete

and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this

form, please write to: U.S. Department of Education, Washington, D.C. 20202-4651. If you have comments or concerns regarding the status of your

individual submission of this form, write directly to: Office of Indian Education, U.S. Department of Education, 400 Maryland Avenue, S.W.,

LBJ/Room 3W203, Washington, D.C. 20202-6335. OMB Number: 1810-0021 Expiration Date: 07/31/2019.

Elk Grove Unified School District – Excellence by Design

Members of the Board Beth Albiani Nancy Chaires Espinoza Carmine S. Forcina Chet Madison, Sr. Dr. Crystal Martinez-Alire Anthony “Tony” Perez Bobbie Singh-Allen 5900 Bamford Drive, Sacramento, CA 95823

Alan Williams Administrator

916.399.9890

allwilli@egusd.net

______________________________________________________________________________________

EXPECTATIONS of PARENT/GUARDIAN(s) TO ENSURE STUDENT SUCCESS The EGUSD Virtual Academy offers an alternative educational model to students and families who desire an online, independent study environment. Through the EGUSD Virtual Academy, students are challenged to learn the content of core and elective subjects that have the full scope of content and rigor as traditional classes. Unlike a traditional school environment, the daily schedule is highly flexible and learning on most days can take place from home or wherever the student needs to be. Successful students in a virtual environment have the support of an attentive learning coach or mentor. Success in this environment requires responsibility and commitment on the part of the student and the responsible adult. At the EGUSD Virtual Academy, we support all students in their pursuits of academic success. We know that parents who adhere to the following expectations are assisting their students to be academically successful in this online independent study environment.

• I have read and understand the Expectations of Student Success in the EGUSD Virtual Academy. • I will ensure that my student plans and adheres to a study and coursework schedule each week. • I will login to the Connexus Online Learning System daily. • I will check Connexus email on a daily basis. • I will meet with the EGVA staff or teachers as required/scheduled. • I understand that my student may be disenrolled from the Virtual Academy if he or she fails to make academic progress in this environment.

EXPECTATION OF STUDENT TO ENSURE SUCCESS The EGUSD Virtual Academy offers an alternative educational model to students and families who desire an online, independent study environment. Through the EGUSD Virtual Academy students are challenged to learn the content of core and elective subjects that have the full scope of content and rigor as traditional classes. Unlike a traditional school environment, the daily schedule is highly flexible and learning on most days can take place from home or wherever the student needs to be. Successful students in a virtual environment share similar characteristics. Success in this environment requires responsibility and commitment. At the EGUSD Virtual Academy, we support all students in their pursuits of academic success, and, therefore, we hold the following expectations of our students.

• I will plan, in advance, my study and coursework schedule for each week. • I plan to spend a minimum of five hours per day, five days per week, on my schoolwork. • I will login to the Connexus Online Learning System daily. • I will check Connexus email on a daily basis. • I will respond to my teachers’ emails regarding my work. • I will participate in Class Connect sessions when they are offered by my teachers. • When taking PE or Health, I will communicate regularly with my teacher(s) through regular email. • I understand that I need to engage in and log appropriate physical education activities as part of my requirement for my PE class. • I will come in to meet with the EGVA staff or teachers as required, typically about four times per semester. • I will call or email my teacher when I am stuck or having a problem.

____________________________ __________________________________ _______________ Printed Parent/Guardian Name Signature Date ____________________________ __________________________________ ______________ Printed Student’s Name Signature Grade

EGUSD Student Opt-Out Form 2016-2017

This form provides parents the opportunity to opt their student out of public media coverage, posting of student images and names through EGUSD digital communication tools, release of directory information, films, and family life education. Please read each section of the form carefully.

If you would like to opt your child out of any of the following sections, please fill out your child’s information (one form per child), check the associated box and sign the form.

Please note: This is an OPTIONAL form. The form should only be returned to the school if you wish to opt your child out of one of these areas.

If you have any questions about this form, please contact EGUSD Communications at (916) 686-7732. Student Name:_____________________________________ ID#______________ Address: _________________________________________ Phone:____________ School: __________________________________________ Grade:____________

Multimedia Withhold Form There are occasions when news media are on school campuses to interview, photograph and videotape students for print and broadcast stories. Many of these stories are positive and highlight the good things happening in EGUSD schools. However, there are times when the media seeks access to our schools on more controversial issues. At all times our goal is to maintain student security and privacy.

If you want your child to be excluded from media stories, please check the box below and sign the form. Please know that there are times when the media will interview or photograph students off campus or without checking in with the front office. This form only acts as a guide to media coverage. It does not guarantee that your child will not be interviewed or photographed.

____I DO NOT want media representatives to publish/broadcast interviews with or photographs/video identifying my child.

Posting of Student Images and Names on EGUSD Digital Communication Tools

EGUSD offers a number of opportunities to publicize positive school and student events and accomplishments through district and school digital communication tools. Parents have the choice to withhold their student’s images (photos and video) and name from being posted by checking the area below. The publication of student image(s) along with both first and last name requires prior written consent of the student’s parent/guardian.

The only exception to this rule is the posting of student photos with first and last name into an EGUSD administrative system such as the student information system (SISWeb) or the library system. These are closed systems that only EGUSD teachers, administrators and limited support staff have access through password protected logons. There is no opt-out of these closed systems.

By checking the box below you are choosing to NOT allow the posting of your students’ name or image through digital communication tools. Please know that this will result in your students’ name not being published electronically for recognitions, student honor roll, awards, events, contests, school newspaper articles and clubs.

_____I DO NOT want my student’s image and name posted through any Elk Grove Unified digital communication tools.

EGUSD Student Opt-Out Form 2016-2017, continued

Release of Directory Information/Yearbook Information

Pursuant to FERPA and the California Education Code, the District may release directory information to certain persons or organizations, as specified in this handbook, when it is requested. Directory information may include a student’s name, photograph, address, telephone information, email address, major field of study, participation in officially recognized activities and sports, weight and height of members of the athletic teams, dates of attendance, degrees and awards received, and the most recent previous public or private school attended. In the case of students who have been identified as having special needs or homeless, no material can be released without parent or guardian consent. Parents and guardians can opt-out of having their child’s directory information released by checking the box below and signing the form.

____I DO NOT want my student’s directory information to be released.

Movies and Videos

The district has a policy limiting the types of movies shown in classrooms. Rated PG-13 movies may only be shown to grades 6-12. If you do not want your child to view PG-13 rated movies during the 2016-2017 school year, please check the box below: ___I DO NOT want my child to view PG-13 rated movies. I prefer that my child be given alternative assignments. Rated R movies may only be shown to grades 9-12. If you do not want your child to view R rated movies during the 2016-2017 school year, please check the box below: ___I DO NOT want my secondary student to view R rated movies. I prefer that my child be given alternative assignments.

Elementary Family Life Education Each year, district elementary schools offer a unit in Family Life Education to students in grades 5 and 6. The district’s family life curriculum is based on abstinence and acknowledges the family as the primary provider of family life education. Under state law, parents have the right to excuse their children from the Family Life Program. If you do not want your child to participate in the Family Life Program during the 2016-2017 school year, please check the box below and sign the form. ___I DO NOT want my child to participate in the Family Life program. I would prefer that my child be given alternative assignments.

Parent/Guardian Signature:________________________________________ Date:________________

GUIDE TO IMMUNIZATIONS REQUIRED FOR SCHOOL ENTRY

GRA DES T K/ K- 12

Entry Requirements by Age and rade Before Entering:

Polio (OPV or lPV)

4 doses (3 doses OK if one was given on or after 4th birthday)

4 doses (3 doses OK if one was given on or after 2nd birthday)

Diphtheria, Tetanus,and Pertussis

5 doses of DTaP,DTP, or OT (4 doses OK if one was given on or after 4th birthday)

4 doses of DTaP,DTP, OT,Tdap,orTd (3 doses ok if last dose was given on or after 2nd birthday. At least one dose must beTc;lap or DTaP/DTP given on or after 7th birthday for all 7th-12th graders.)

1 dose of Tdap (Or DTP/DTaP given on or after the 7th birthday.)

Measles, Mumps, and Rubella (MMR or MMR-V)

2 doses (Both given on or after 1st birthday. Only one dose of mumps and rubella vaccines are required if given separately.)

1 dose (Dose given on or after 1st birthday. Mumps vaccine is not required if given separately.)

2 doses of MMR or any measles-contain- ing vaccine

(Both doses given on or after 1st birthday.)

Hepatitis B (Hep Bor HBV)

3 doses

VariceIla (chickenpox, VAR, MMR-V,or VZV)

1 dose 1 dose for ages 7-12 years.

2 doses for ages 13-17 years.

*New admissions to 7th grade should also meet the requirements for ages 7-17 years.

INSTRUCTIONS:

California schools are required to check immunization records for all new student admissions at Kindergarten!rK through 12thgrade and all students advancing to 7th grade before entry.

1. Notify parents of required immunizations and collect immunization records.

2. Copy the date of each vaccine from the child's immunization record to the California School Immunization Record (Blue Card, CDPH-286) and/or supplemental Tdap sticker [PM 286 S (01/11)] or enter into an approved electronic system that prins a Blue Card.

3. Compare number of doses on the Blue Card to the requirements above.

4. Determine whether child can be admitted.

Continued on next page.

Questions? Visit ShotsForSchool.org

or Contact your local health

department (bit.do/immunization)

IMM-231 (10/15) California Department of Public Health • Immunization Branch· ShotsForSchool.org

GUIDE TO IMMUNIZATIONS REQUIRED FOR SCHOOL ENTRY GRADES TK/K-12 (continued)

ADMIT A CHILD WHO:

• Has all immunizations required for their age or grade,or

• Submits a personal beliefs exemption (before January 1, 2016) for missing shot(s) and immunization records with dates for all required shots not exempted,or

• Submits a physician's written statement of a medical exemption for missing sho(s) and immunization records with dates for all required shots not exempted.

ADMIT A CHILD CONDITIONALLY IF:

• He/she is missing a dose(s) in a series, but the next dose is not due yet. (This means the child has received at least one dose in a series and the deadline for the next dose has not passed.) The child may not be admittecl if the deadline has passed or has not yet received the 1st dose.

• Has a temporary medical exemption to certainvaccine(s) and has submitted an immunization record for vaccines not exempted.

When Missing Doses Can Be Given:

Vaccine Age (Years)

Missing Dose

Earliest Date After Previous Dose

Deadline After Previous Dose

Polio 2nd 6 weeks 10 weeks

3rd 6 weeks 12 months

4-6 4th If the 3rd dose was given before the 4th birthday,one more dose is required before admission.

7-17 4th If the 3rd dose was given before the 2nd birthday,one more dose is required before admission.

DTaP, DTP, or DT Under 7 2nd or 3rd 4 weeks 8 weeks

4th 6 months 12 months

5th If the 4th dose was given before the 4th birthday, one more dose is required before admission.

DTaP, DTP, DT, Tdap,or Td

7 & 01der 2nd 4 weeks 8 weeks

3rd 6 months 12 months

4th If the 3rd dose was given before the 2nd birthday, one more dose is requireq before admission.

MMR 2nd 1 month 3 months

HepB 4-6 2nd 1 month 2 months

3rd 2 months after 2nd dose and at least 4 months after 1st dose

6 months after 2nd dose andat least 4 months after 1stdose

Varicella 1317 2nd 4 weeks 3 months

DO NOT ADMIT A CHILOWHO:

Does not fit one of the previous categories. Refer parents to their physician with a written notice indicating which doses are needed.

FOLLOW-UP IS REQUIRED AFTER ADMISSION IF:

• Child has a temporary medical exemption.

• Awaiting records for transfers from within California or another state. School may allow up to 30 schooldays before exclusion.

Maintain a list qf unimmunized children (exempted or admitted conditionally), so they can be excluded quickly if ah outbreak occurs.

Notify parents of the deadline for missing doses. Review records every 30 days until all required doses are received.

CDPH

IMM-231 (10/15) California Department of Public Health • Immunization Branch • ShotsForSchool.org