EL MOLINO HIGH SCHOOL
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1 EL MOLINO HIGH SCHOOL California Distinguished School 1988, 1992, 2001 and th GRADE REGISTRATION PROCEDURES To enroll a student the following documents are needed at the time of registration: 1. Completed Registration Packet 2. Immunization Records (see reverse side for immunizations requirements) Students will not be enrolled without proof of immunizations including a TDaP booster. 3. Proof of Age 4. Last Report Card and Testing results if possible 5. *Proof of residence (utility bill with physical address, lease agreement, etc.) *If the proof of residence is not within the El Molino High School boundaries, it is necessary to complete an interdistrict or intradistrict transfer form. This form must be approved by both schools prior to enrollment into El Molino High School and needs to be submitted with the registration packet. A parent or guardian must enroll the student. If the parent or guardian is not present, the student will not be enrolled unless the parent has signed in front of a notary or qualified school personnel a Caregiver Authorization Affidavit. In the event that it is not possible to contact a parent or legal guardian a Caregiver s Authorization Affidavit must be completed. The student needs to be enrolled using their legal name. If the student is using a name different from that on the Birth Certificate, legal documentation of the name change is needed. Any court documentation regarding this student should also be presented at the time of registration. 8 th Grade Registration Registrar s Office: (707) Fax: (707) Wednesday, March 1 st 3:30-7:00pm & Thursday, March 9 th 3:00-6:30pm WEST SONOMA COUNTY UNION HIGH SCHOOL NOTICE OF NON-DISCRIMINATION West Sonoma County Union High School District policy prohibits discrimination and/or harassment of students, employees and job applicants at any district site or activity on the basis of actual or perceived race, color, national origin, ancestry, ethnic group identification, medical condition, genetic condition, genetic information, disability, gender, gender identity, gender expression, sex, sexual orientation, age, political affiliation, organizational affiliation, veteran status, marital status, or parental status. Please direct inquiries regarding the District s non-discrimination policies to any school or district administrator.
2 PARENTS GUIDE TO IMMUNIZATIONS REQUIRED FOR SCHOOL ENTRY Entry Requirements by Age and Grade: Vaccine 4-6 Years Old Elementary School at Transitional-Kindergarten/ Kindergarten and Above 7-17 Years Old Elementary or Secondary School 7th Grade* Polio (OPV or IPV) 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 (DTaP, DTP, DT, or Tdap) 5 doses of DTaP, DTP, or DT (4 doses OK if one was given on or after 4th birthday) 4 doses of DTaP, DTP, DT, Tdap, or Td (3 doses OK if last dose was given on or after 2nd birthday. At least one dose must be Tdap 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 doses 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-containing vaccine (Both doses given on or after 1st birthday.) Hepatitis B (Hep B or HBV) 3 doses Varicella (chickenpox, VAR, MMR-V or VZV) 1 dose 1 dose for ages 7-12 years. 2 doses for ages years. *New admissions to 7th grade should also meet the requirements for ages 7-17 years. WHY YOUR CHILD NEEDS SHOTS: The California School Immunization Law requires that children be up to date on their immunizations (shots) to attend school. Diseases like measles spread quickly, so children need to be protected before they enter. California schools are required to check immunization records for all new student admissions at Kindergarten or Transitional Kindergarten through 12th grade and all students advancing to 7th grade before entry. THE LAW: Health and Safety Code, Division 105, Part 2, Chapter 1, Sections ; California Code of Regulations, Title 17, Division 1, Chapter 4, Subchapter 8, Sections WHAT YOU WILL NEED FOR ADMISSION: To attend school, your child s Immunization Record must show the date for each required shot above. If you do not have an Immunization Record, or your child has not received all required shots, call your doctor now for an appointment. If a licensed physician determines a vaccine should not be given to your child because of medical reasons, submit a written statement from the physician for a medical exemption for the missing shot(s), including the duration of the medical exemption. A personal beliefs exemption is no longer an option for entry into school; however, a valid personal beliefs exemption filed with a school before January 1, 2016 is valid until entry into the next grade span (7th through 12th grade). Valid personal beliefs exemptions may be transferred between schools in California. For complete details, visit ShotsforSchool.org. You must also submit an immunization record for all required shots not exempted. Questions? Visit ShotsForSchool.org or contact your local health department (bit.do/immunization). IMM-222 School (1/16) California Department of Public Health Immunization Branch ShotsForSchool.org
3 WSCUHSD STUDENT REGISTRATION ANALY EL MOLINO LAGUNA COMMUNITY DAY Has your student ever attended school in WSCUHSD? Yes No PLEASE PRINT STUDENT S LEGAL NAME a e o irth ertifi ate Legal First Name Legal Middle Name Legal Last Name Other Legal Name (if applicable) Male Female Birth date: Parent/Guardian First Name Last Name Home Phone Cell Phone Parent/Guardian First Name Last Name Home Phone Cell Phone Residence Address Apt# City State Zip Mailing Address (if different) Apt# City State Zip (P.O. Box or house # and street name) Grade Student Last Name: First Name: 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 check up to five racial categories) The above part of the question is about ethnicity, not race. No matter what you select above, please continue to answer the following by marking one or more boxes to indicate what you consider your race to be. American Indian or Alaskan Native (100) (Persons having origins in any of the original people 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) American or Black (600) White (700) (Persons having origins in any of the original peoples of Europe, North Africa, or the Middle East) Decline to state PARENT EDUCATION- Check the response that describes the education level of the most educated parent. Graduate Degree or Higher (10) College Graduate (11) So e College o Associate s Deg ee High School Graduate (13) Not a High School Graduate (14) Decline to state (6) Date student first attended school in the U.S. Date student first attended school in California BIRTHPLACE: City: State: Country: U.S. Citizen: Yes No WEST SONOMA COUNTY UNION HIGH SCHOOL NOTICE OF NON-DISCRIMINATION West Sonoma County Union High School District policy prohibits discrimination and/or harassment of students, employees and job applicants at any district site or activity on the basis of actual or perceived race, color, national origin, ancestry, ethnic group identification, medical condition, genetic condition, genetic information, disability, gender, gender identity, gender expression, sex, sexual orientation, age, political affiliation, organizational affiliation, veteran status, a ital status, o pa e tal status. Please di ect i ui ies ega di g the Dist ict s o -discrimination policies to any school or district administrator.
4 HOME LANGUAGE SURVEY: Indicate only one language (most frequently used) per line: 1. What language/dialect does your son/daughter most frequently use at home? 2. Which language/dialect did your son/daughter learn when he/she first began to talk? 3. What language/dialect do you most frequently speak to your child? 4. Has your child ever been given the CELDT Test (California English Language Development Test)? Yes No I do t k o In which language do you wish to receive written communications from the school? English Spanish Residence where is your child/family currently living? (federally mandated by NCLB) Please check appropriate box: In a single family permanent residence (house, apartment, condo, mobile home) Dou led up shari g housi g ith other fa ilies/i di iduals due to e o o i hardship or loss) (11) In a motel/hotel (09) Unsheltered (car/campsite) (12) Other (15) (please specify) In a shelter or transitional housing program (10) Parent/Guardianship Information (with whom the student lives) check all that apply Father Mother Both tep Father tep Mother Guardian Foster/Group Home Other Is the above (checked) person s the stude t s LEGAL guardia? Yes No If No, please o plete a Caregi er Affida it If there is a legal custody agreement regarding this student, please check one: Joint Custody Sole Custody Guardian PLEASE COMPLETE INFORMATION BELOW FOR PARENT(S)/GUARDIAN WITH WHOM THE STUDENT LIVES: 1. Father Step Father/Guardian (check one) Full Name: Employer: City: Daytime Phone # ( ) 2. Mother Step Mother/Guardian (check one) Full Name: Employer: City: Daytime Phone # ( ) DUPLICATE MAILING If divorced/separated & joint custody allows duplicate mailing/information to be given to other parent, Please include their name, address, and phone number: Full Name: Phone # ( ) Mailing Address: City: State: Zip code: MOST RECENT SCHOOL ATTENDED: School Address/City/State/Zip Grade(s) Date(s) Are there psy hologi al or o fide tial reports a aila le fro your hild s for er s hool? Yes No Has your child ever been suspended? Yes No Has your child ever been expelled? Yes No What special services has your child received? (please check all boxes that apply) Special Education: Resource (RSP) Special Day Class (SDC) Speech/Language 504 Other: Gifted (GATE) Remedial Math Remedial Reading Counseling English Language Development Help to Improve Attendance/Behavior Other (Specify) Signature of Parent/Guardian: Date: Student Last Name: First Name: Permanent ID: PLEASE COMPLETE INFORMATION ON THE OTHER SIDE OF THIS FORM
5 WEST SONOMA COUNTY UNION HIGH SCHOOL DISTRICT EMERGENCY MEDICAL INSTRUCTION FORM Student Name: Date of Birth: Address: Phone: In case of illness or emergency to the above named student, the school is authorized to contact individuals listed below and release the student to him/her. Please number each person 1, 2, 3 etc. in order of contact. ( )Contact Mother: Name: Phone: ( )Contact Father: Name: Phone: ( )Contact #1: Name: Phone: ( )Contact #2: Name: Phone: ( )Contact #3: Name: Phone: Physician: Name: Phone: Dentist: Name: Phone: Please list any food/medication/bee sting allergies: Please list any chronic health concerns (asthma, diabetes, etc.) Please list any medications taken on a regular or as needed basis (include inhalers, prescriptions, and over the counter medication) and how often uses (see medication policy below): Does your child currently have a health insurance plan (for example, Medi-Cal, Kaiser, Blue Shield, etc)? Yes No If yes who is the insurer? I request that my child receives first aid services whenever such services are deemed necessary. I authorize that my child be attended by a licensed physician and/or taken to the nearest hospital in the event that his/her condition deems necessary. I will accept the judgment of the person in charge. This is effective until written notice of cancellation is given by me. Signature of Parent/Guardian: Date: In the event of a life threatening allergic reaction, I authorize school personnel to administer emergency treatment (EPI-PEN, epinephrine to my child. Signature of Parent/Guardian: Date: MEDICATION POLICY Note: ALL medications, including over the counter, that is brought to school MUST be in its original container labeled with the student s name. The student MUST have a signed form from the doctor and parent on file in the school Health Office. The medication may be carried with the student with written permission or kept in a locked cabinet in the Health Office. Please contact the school Health Technician with any questions. NOTICE OF NON-DISCRIMINATION West Sonoma County Union High School District policy prohibits discrimination and/or harassment of students, employees and job applicants at any district site or activity on the basis of actual or perceived race, color, national origin, ancestry, ethnic group identification, medical condition, genetic condition, genetic information, disability, gender, gender identity, gender expression, sex, sexual orientation, age, political affiliation, organizational affiliation, veteran status, marital status, or parental status. Please direct inquiries regarding the District s non-discrimination policies to any school or district administrator. Revised 5/28/14
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