office use only · chinese health history. title: microsoft word - ausd enrollment revisions -...

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STUDENT ENROLLMENT FORM 7RGD\¶V 'DWHBBBBBBBBBBBBBBBB (QUROOLQJ 6FKRROBBBBBBBBBBBBBBBBBBB (QUROOPHQW 'DWHBBBBBBBBBBBBBB 6WXGHQW ,'BBBBBBBBBBBBBBBBBBBBBBBB STUDENT INFORMATION BBBBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBB BBBBBBBBBBBBB /HJDO /DVW 1DPH /HJDO )LUVW 1DPH 0LGGOH 1DPH 6XIIL[-U ,,, HWF $.$1LFNQDPH BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBBBBBB BBBBBB BBBBBBBBBBBBB BBBBBBBBBBBBBBBBBB +RPH $GGUHVV 6WUHHW DQG $SW &LW\ 6WDWH =LS +RPH 3KRQH BBBBBBB BBBBBBBBBBBBB BBBBBBBBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBBBBBBBB *UDGH 0DOH )HPDOH %LUWKGDWH %LUWK &LW\ %LUWK 6WDWH3URYLQFH %LUWK &RXQWU\ 1HHGHG 2QO\ IRU 86 &DQDGD DQG 0H[LFR ,I ERUQ RXWVLGH RI WKH 8QLWHG 6WDWHV ZKHQ GLG \RXU FKLOG ILUVW HQWHU WKH 8QLWHG 6WDWHV" PPGG\\\\ BBBBBBBBBBBBBB FAMILY INFORMATION (NOT EMERGENCY CONTACT INFORMATION) Student Lives %RWK 3DUHQWV )DWKHU RQO\ 0RWKHU RQO\ /HJDO *XDUGLDQV With )DWKHU DQG 6WHSPRWKHU 0RWKHU DQG 6WHSIDWKHU )RVWHU 3DUHQWV 2WKHU BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB Is this student court placed or a foster child? <HV 1R ,I FRXUW RUGHUHG SOHDVH SURYLGH FRXUW GRFXPHQWDWLRQ FATHER/LEGAL GUARDIAN NAME BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBB +RPH &HOO BBBBBBBBBBBBBBBBB +RPH &HOO /DVW )LUVW 3ULPDU\ 3KRQH :RUN 2WKHU 6HFRQGDU\ 3KRQH :RUN 2WKHU MOTHER/LEGAL GUARDIAN NAME BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBB +RPH &HOO BBBBBBBBBBBBBBBBB +RPH &HOO /DVW )LUVW 3ULPDU\ 3KRQH :RUN 2WKHU 6HFRQGDU\ 3KRQH :RUN 2WKHU Primary Contact (please check one only): )DWKHU/HJDO *XDUGLDQ 0RWKHU/HJDO *XDUGLDQ Preferred Parent’s Email Address (one only please):BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB Home Correspondence Language (used for district/school mailings) (QJOLVK &KLQHVH 6SDQLVK 9LHWQDPHVH Home Phone Language (used for phone calls home) (QJOLVK &DQWRQHVH 0DQGDULQ 6SDQLVK 9LHWQDPHVH STATE MANDATED INFORMATION (Required by the California State Department of Education) 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? (Required for ALL students. Please check up to a maximum of five racial categories) BB $PHULFDQ ,QGLDQ RU $ODVND 1DWLYH (A person having origins in any of the original peoples of North, South, or Central America and maintains a tribal affiliation or community attachment) BB &KLQHVH BB .RUHDQ BB $VLDQ ,QGLDQ BB +PRQJ BB %ODFN RU $IULFDQ $PHULFDQ BB )LOLSLQR BB -DSDQHVH BB 9LHWQDPHVH BB /DRWLDQ BB &DPERGLDQ BB 2WKHU $VLDQ BB :KLWH (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa) BB +DZDLLDQ BB 6DPRDQ BB *XDPDQLDQ BB 7DKLWLDQ BB 2WKHU 3DFLILF ,VODQGHU +DYH \RX RU DQ\RQH LQ \RXU IDPLO\ ZRUNHG LQ DJULFXOWXUH ILVKLQJ RU IRRG SURFHVVLQJ LQ WKH ODVW WKUHH \HDUV" <HV 1R Parent/Guardian Education Level SOHDVH FKHFN RQO\ WKH HIGHEST HGXFDWLRQ OHYHO FRPSOHWHG E\ HLWKHU SDUHQWJXDUGLDQ 1RW D KLJK VFKRRO JUDGXDWH +LJK VFKRRO JUDGXDWH 6RPH FROOHJH LQFOXGHV $$ GHJUHH &ROOHJH JUDGXDWH *UDGXDWH VFKRRO3RVW *UDGXDWH WUDLQLQJ 'HFOLQHG WR VWDWH RU XQNQRZQ 'LG \RXU FKLOG DWWHQG SUHVFKRRO" <HV 1R ,I \HV ZKLFK SUHVFKRRO" BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB :KHQ GLG \RXU FKLOG ILUVW HQUROO LQ D 8QLWHG 6WDWHV .± VFKRRO" PPGG\\ BBBBBBBBBBBBBBBBB *UDGH BBBBBBBBB :KHQ GLG \RXU FKLOG ILUVW HQUROO LQ D &DOLIRUQLD .± VFKRRO" PPGG\\ BBBBBBBBBBBBBBBBB *UDGH BBBBBBBBB 'R \RX FXUUHQWO\ RZQ RU UHQW WKH KRPH DW WKH DGGUHVV \RX OLVWHG DERYH" <HV 1R OFFICE USE ONLY 7HDFKHU +RPHURRP )RUP 3URFHVVHG %\BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB $)) 925 &6,6 307 5(6 +/6 Form 3730 Rev. 03/11 OFFICE USE ONLY Please Print Clearly with Black or Blue Ink

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Page 1: OFFICE USE ONLY · Chinese Health History. Title: Microsoft Word - ausd enrollment revisions - 1.1a.doc Author: chen_david Created Date: 20130205182805Z

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S T U D E N T E NR OL L M E NT FOR M ��

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�(QUROOPHQW�'DWH�BBBBBBBBBBBBBB�6WXGHQW�,'�BBBBBBBBBBBBBBBBBBBBBBBB��

STUDENT INFORMATION �

�BBBBBBBBBBBBBBBBBBBBBBBB��BBBBBBBBBBBBBBBBBBBBBBBBBB��BBBBBBBBBBBBBBBBBBBBBBBBB��BBBBBBBBBBBBBBB��BBBBBBBBBBBBB��/HJDO�/DVW�1DPH��������� �������/HJDO�)LUVW�1DPH� ������������������������0LGGOH�1DPH������������������������������6XIIL[�-U���,,,��HWF����$.$�1LFNQDPH��

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�BBBBBBB������ ������� ��������BBBBBBBBBBBBB�BBBBBBBBBBBBBBBBBBBBBBBBBBBB� BBBBBBBBBBBBBBBBBB�BBBBBBBBBBBBBBBBBBBBBBB�������������*UDGH��������0DOH���)HPDOH����%LUWKGDWH�� %LUWK�&LW\� ������� � %LUWK�6WDWH�3URYLQFH�����%LUWK�&RXQWU\����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������1HHGHG�2QO\�IRU�86��&DQDGD��DQG�0H[LFR���

�,I�ERUQ�RXWVLGH�RI�WKH�8QLWHG�6WDWHV��ZKHQ�GLG�\RXU�FKLOG�ILUVW�HQWHU�WKH�8QLWHG�6WDWHV"��PP�GG�\\\\��BBBBBBBBBBBBBB��� ��

FAMILY INFORMATION (NOT EMERGENCY CONTACT INFORMATION)

Student Lives� �%RWK�3DUHQWV� � �)DWKHU�RQO\� � �0RWKHU�RQO\� � �/HJDO�*XDUGLDQ�V����������With�� �)DWKHU�DQG�6WHSPRWKHU� �0RWKHU�DQG�6WHSIDWKHU� �)RVWHU�3DUHQWV�� �2WKHU��� � � � � � � � � � � � ��BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB�

Is this student court placed or a foster child? � <HV ��� 1R����,I�FRXUW�RUGHUHG��SOHDVH�SURYLGH�FRXUW�GRFXPHQWDWLRQ��

FATHER/LEGAL GUARDIAN NAME

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MOTHER/LEGAL GUARDIAN NAME

BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB� �BBBB�BBBBBBBBBBBBB� �+RPH� �&HOO� �BBBB�BBBBBBBBBBBBB���� �+RPH�� �&HOO�/DVW��)LUVW� 3ULPDU\�3KRQH��� �:RUN�� �2WKHU�� 6HFRQGDU\�3KRQH��� �:RUN� �2WKHU��������

Primary Contact (please check one only): �)DWKHU�/HJDO�*XDUGLDQ������ �0RWKHU�/HJDO�*XDUGLDQ�

Preferred  Parent’s  Email  Address  (one only please):BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB�

Home Correspondence Language (used for district/school mailings)��� (QJOLVK� &KLQHVH� 6SDQLVK� 9LHWQDPHVH��

Home Phone Language (used for phone calls home)��� (QJOLVK���� &DQWRQHVH� 0DQGDULQ� 6SDQLVK� 9LHWQDPHVH���

STATE MANDATED INFORMATION (Required by the California State Department of Education) 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? (Required for ALL students. Please check up to a maximum of five racial categories)

BB�$PHULFDQ�,QGLDQ�RU�$ODVND�1DWLYH��(A person having origins in any of the original peoples of North, South, or Central America and maintains a tribal affiliation or community attachment) BB�&KLQHVH�BB�.RUHDQ��BB�$VLDQ�,QGLDQ�BB�+PRQJ�

BB�%ODFN�RU�$IULFDQ�$PHULFDQ�BB�)LOLSLQR�BB�-DSDQHVH�BB�9LHWQDPHVH�BB�/DRWLDQ��BB�&DPERGLDQ�BB�2WKHU�$VLDQ�

BB�:KLWH��(A person having origins in any of the original peoples of Europe, the Middle East, or North Africa) BB�+DZDLLDQ��BB�6DPRDQ�BB�*XDPDQLDQ�BB�7DKLWLDQ�BB�2WKHU�3DFLILF�,VODQGHU�

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Parent/Guardian Education Level��SOHDVH�FKHFN�RQO\�WKH�HIGHEST�HGXFDWLRQ�OHYHO�FRPSOHWHG�E\�HLWKHU�SDUHQW�JXDUGLDQ����

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OFFICE USE ONLY 7HDFKHU� +RPHURRP� )RUP�3URFHVVHG�%\�BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB�$))� 925�&6,6� 307�5(6� +/6�Form 3730 Rev. 03/11 � �

OFFICE USE ONLY

�Please Print Clearly with Black or Blue Ink

Page 2: OFFICE USE ONLY · Chinese Health History. Title: Microsoft Word - ausd enrollment revisions - 1.1a.doc Author: chen_david Created Date: 20130205182805Z

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OTHER CHILDREN LIVING IN THE HOME �

BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB� BBBBBBBBBBBBBBBBBBBBB�BBBBBBBBBBBBB� BBBBBBBBBBBBBBBBBBBB� BBBBBBBBBB�)LUVW�DQG�/DVW�1DPH�� ������� � 5HODWLRQVKLS� ����� %LUWKGDWH� &XUUHQW�6FKRRO� � *UDGH��

BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB� BBBBBBBBBBBBBBBBBBBBB�BBBBBBBBBBBBB� BBBBBBBBBBBBBBBBBBBB� BBBBBBBBBB�)LUVW�DQG�/DVW�1DPH�� ������� � 5HODWLRQVKLS� ����� %LUWKGDWH� &XUUHQW�6FKRRO� � *UDGH��

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ACADEMIC HISTORY �

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� �0RRU�)LHOG�(DUO\�(GXFDWLRQ�&HQWHU� �0DUJXHULWD� �$OKDPEUD�+LJK�6FKRRO�� �%DOGZLQ� �0RQWHUH\�+LJKODQGV� �0DUN�.HSSHO�+LJK�6FKRRO�� �%ULJKWZRRG� �1RUWKUXS� �6DQ�*DEULHO�+LJK�6FKRRO�� �(PHU\�3DUN� �3DUN� �&HQWXU\�+LJK�6FKRRO�� �)UHPRQW� �5DPRQD� �,QGHSHQGHQFH�+LJK�6FKRRO�� �*DUILHOG� �5HSHWWR� �� �*UDQDGD� �<QH]� ��

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Previous Schools Attended (please include ALL previous schools):

BBBBBBBBBBBBBBBBBBBBBBBBBBBB� BBBBBBBBBBBBBBBBBBBBB�BBBBBBBBBBBBBBBBBBBBB�BBBBBBBBBBBBBBBBBBBBB�BBBBBBBBBBBB�1DPH�RI�/DVW�6FKRRO� � 6FKRRO�'LVWULFW������������������ &LW\� ������������� ����������� 6WDWH���&RXQWU\� � *UDGH�V���BBBBBBBBBBBBBBBBBBBBBBBBBBBB� BBBBBBBBBBBBBBBBBBBBB�BBBBBBBBBBBBBBBBBBBBB�BBBBBBBBBBBBBBBBBBBBB�BBBBBBBBBBBB�1DPH�RI�3UHYLRXV�6FKRRO� � 6FKRRO�'LVWULFW������������������ &LW\� ������������� ����������� 6WDWH���&RXQWU\� � *UDGH�V���BBBBBBBBBBBBBBBBBBBBBBBBBBBB� BBBBBBBBBBBBBBBBBBBBB�BBBBBBBBBBBBBBBBBBBBB�BBBBBBBBBBBBBBBBBBBBB�BBBBBBBBBBBB�1DPH�RI�3UHYLRXV�6FKRRO� � 6FKRRO�'LVWULFW������������������ &LW\� ������������� ����������� 6WDWH���&RXQWU\� � *UDGH�V�����

SCHOOL AND SPECIALIZED EDUCATION PROGRAMS 0\�FKLOG�LV�UHFHLYLQJ�RU�KDV�UHFHLYHG�VHUYLFHV�LQ��SOHDVH�FKHFN�DOO�WKDW�DSSO\����

������3ODQ�� ��6SHFLDO�(GXFDWLRQ�,(3��SOHDVH�VSHFLI\�BBBBBBBBBBBBBBBBBBBBB���$OWHUQDWLYH�%LOLQJXDO�3URJUDP��ZDLYHU�� ��6SHHFK�/DQJXDJH�6HUYLFHV��,(3����(QJOLVK�/DQJXDJH�'HYHORSPHQW� ��7LWOH�,���*LIWHG�DQG�7DOHQWHG�(GXFDWLRQ��*$7(�� ��2WKHU��SOHDVH�VSHFLI\�BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB�

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�0\�VLJQDWXUH�FHUWLILHV�WKDW�DOO�LQIRUPDWLRQ�LV�DFFXUDWH���,Q�RUGHU�WR�NHHS�P\�FKLOG�VDIH��,�ZLOO�UHSRUW�DQ\�FKDQJHV�RI�DGGUHVV��WHOHSKRQH��RU�HPHUJHQF\�LQIRUPDWLRQ�WR�WKH�VFKRRO�VLWH�ZLWKLQ�ILYH�GD\V�� BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB���� � � BBBBBBBBBBBBBBBBBBBBBBBBBBBBBB�3DUHQW���/HJDO�*XDUGLDQ�6LJQDWXUH� � ������������ � � � � 'DWH����

Page 3: OFFICE USE ONLY · Chinese Health History. Title: Microsoft Word - ausd enrollment revisions - 1.1a.doc Author: chen_david Created Date: 20130205182805Z
Page 4: OFFICE USE ONLY · Chinese Health History. Title: Microsoft Word - ausd enrollment revisions - 1.1a.doc Author: chen_david Created Date: 20130205182805Z
Page 5: OFFICE USE ONLY · Chinese Health History. Title: Microsoft Word - ausd enrollment revisions - 1.1a.doc Author: chen_david Created Date: 20130205182805Z

1515 W. Mission Road Alhambra, CA 91803

(626) 943-3400 FAX (626) 943-8033 Dear Parents/Guardians: This letter is to inform you of the possibility of your child being transferred to another school within the Alhambra Unified School District, due to maximum student enrollment in certain grade levels at your neighborhood school. The criterion for enrollment of students to another school is based on the date and time the student completes registration. If it becomes necessary to transfer a student, the last enrolled student will be the first student moved to another school. All students transferred to another school will be enrolled in their neighborhood school at the beginning of the following school year. If your student is transferred, it will be the responsibility of the parent/guardian to transport the child to the overflow school. Thank you for your understanding and cooperation. Sincerely, Marsha Gilbert Assistant Superintendent

_____ . . ____ . . ____ . . ____ . . ____ . . ____ . . ____

I acknowledge that I have received information regarding the potential “overflow” of my child due to enrollment at my neighborhood school or school requested under permit provisions. The process for overflow has been explained to me.

Parent’s Name(s) (please print) ______________________________

Home School (permit school) _______________________________

Child’s Name (please print) _________________________________

Parent Signature __________________________________________

Date ___________________________________________________

“EQUAL OPPORTUNITY EMPLOYER”

Page 6: OFFICE USE ONLY · Chinese Health History. Title: Microsoft Word - ausd enrollment revisions - 1.1a.doc Author: chen_david Created Date: 20130205182805Z
AUSD
English Health History
Page 7: OFFICE USE ONLY · Chinese Health History. Title: Microsoft Word - ausd enrollment revisions - 1.1a.doc Author: chen_david Created Date: 20130205182805Z
AUSD
Spanish Health History
Page 8: OFFICE USE ONLY · Chinese Health History. Title: Microsoft Word - ausd enrollment revisions - 1.1a.doc Author: chen_david Created Date: 20130205182805Z
AUSD
Chinese Health History
Page 9: OFFICE USE ONLY · Chinese Health History. Title: Microsoft Word - ausd enrollment revisions - 1.1a.doc Author: chen_david Created Date: 20130205182805Z
Page 10: OFFICE USE ONLY · Chinese Health History. Title: Microsoft Word - ausd enrollment revisions - 1.1a.doc Author: chen_david Created Date: 20130205182805Z
Page 11: OFFICE USE ONLY · Chinese Health History. Title: Microsoft Word - ausd enrollment revisions - 1.1a.doc Author: chen_david Created Date: 20130205182805Z
Page 12: OFFICE USE ONLY · Chinese Health History. Title: Microsoft Word - ausd enrollment revisions - 1.1a.doc Author: chen_david Created Date: 20130205182805Z
Page 13: OFFICE USE ONLY · Chinese Health History. Title: Microsoft Word - ausd enrollment revisions - 1.1a.doc Author: chen_david Created Date: 20130205182805Z