P Check if it applies P Check if it applies

Kidney Disorder

Medical Procedures required at

schoolMedication Prescribed (explain)

Medication needed at school

Menstrual Cramps (severe)

Migraine Headaches medication

requiredMumps

Muscular Dystrophy

Nose Bleeds (Frequent)

Osgood-Schlatter Disease

Physical Activity Limitation

Rheumatic Fever history

Rubella: 3-day Measles

Is the student Hispanic or Latino? Rubeolla: 10-day Measles

No, not Hispanic or Latino Scarlet Fever Name Grade School of AttendanceYes, Hispanic or Latino Scoliosis

Sickle Cell Anemia (explain below)

Tuberculosis

Ulcer

Vision Impairment (glasses/contacts)

Vision Impairment (visual handicap)

Comments:

Race - What is the race of this student?

(select 1 or more)

American Indian or Alaska Native Medical Comments:

Chinese

Japanese

Korean

Vietnamese My child has not participated in any Special Education Programs

Asian Indian My child has been tested but is not in any Special Education Program

Laotian My child has participated or is currently in a Special Education Program

Cambodian and has an IEP

Filipino My child has participated in a Special Education Program but has exited the Please complete the following questions:

Hmong program per

his/her IEP

Which language did your child learn when they first began to talk?

Other Asian FOR OFFICE USE ONLY

Hawaiian Special education program designation Which language does your child most frequently speak at home?

Guamanian

Samoan Which language do you most frequently use when speaking with

Tahitian Registration Comments your child?

Other Pacific Islander Which language is most often spoken by the adults in the home?

B

Black or African American ________________________________________________________White

Revised 2/27/2012 LT

EM

ER

GE

NC

Y C

ON

TA

CT

S

Endocrine Disorder

Hearing Loss

What date did your student first enroll in a United

States school?

Month: ________________

Year: ____________

What date did your student first enroll in a California

school?

Month: ________________

Year: ____________

The above part of the question is about ethnicity,

not race. No matter what you selected please

continue marking one or more boxes to indicate

what you consider your race to be.

ET

HN

IC O

RIG

INS

HO

ME

LA

NG

UA

GE

SU

RV

EY

SP

EC

IAL

ED

UC

AT

ION

Hearing Aid Used

Chicken Pox

Heart Disease/Defect

ME

DIC

AL

IN

FO

RM

AT

ION

NAME OF OTHER STUDENTS IN THE HOME

Name and phone #

(other than parent/guardian)

Relationship to Student

The California Education Code requires schools to determine the language(s) spoken at home by

each student. This information is essential for the school to provide adequate instructional program and

services. As parents or guardians, your cooperation is requested in complying with this legal

requirement. (CA Dept. of Ed. HLS 10/05). Please note that if you respond with a language other than

English to any of these 4 questions, your child may be identified as an English Learner and will receive

appropriate services to support English Language Development.

Cerebral Palsy

Eating Disorder

Cancer/Leukemia

Arthritis

Asthma

Attention Deficit/Hyperactivity

(ADHD)Birth Defect/Chromosome Disorder

Growth Disorder

STUDENT EDUCATIONAL HISTORY

No Known Health Problems

Allergy: Food (explain )

Blood/Blood Products-not given

Allergy:Medication (explain )

Anemia

Allergy:Pollen, dust, hay fever, insects

What date did your student first enter the United

States?

Month: ________________

Year: ____________

Cystic Fibrosis

Blood Disorder/Hemophilia

Epilepsy/Seizure Medication

Required

Diabetic/ Insulin Dependent

___yes___no