Student Registration

Grades 1-6

2016-2017 Colton Joint Unified School District

2016-2017 Registration Form Checklist Grades 1st – 6th

Please use this checklist to verify that you have all of the required documents completed for submission to the school office. All enrollment forms must be completed and signed before your student will be enrolled.

□ Parent/Guardian Picture ID Required The parent/legal guardian must present a Government issued photo identification in order to enroll a child. If you

are not the parent/legal guardian but you are enrolling a minor child who lives in your home, you must complete a Caregiver’s Authorization Affidavit.

□ Child’s Birth Certificate or Other Verification of Birth Date Required Child’s legal birth certificate, Passport or Hospital record of birth.

□ Address Verification Required Please provide one current proof of address such as a recent bill from the gas, trash, water, electric or phone

company; lease agreement or mortgage statement. The document must be dated within 30 days. If you and your child are living with someone, please bring that person with you; along with their current utility bill in their name, and their picture I.D. If none of these items are available you will need to provide two pieces of mail with same name and address and complete a Residential Affidavit (D-118). The Residential Affidavit is subject to a home visit or verification of residency.

□ Child Immunization Record Card Required Before your child can be enrolled, you must provide proof that he/she has been immunized against Polio, DPT

(Diphtheria, Tetanus, and Pertussis), and MMR (Measles, Mumps and Rubella), Hepatitis B, and Varicella. This is mandated by California state law. The dosage requirements are included in this packet. With the passage of Senate Bill 277 effective, January 1, 2016, we no longer accept personal beliefs or religious waivers.

□ Custody Order Paperwork If Applicable

If there is a legal custody agreement or court order regarding this student you must provide copies at the time of enrollment.

□ Program Participation If Applicable If your child receives services for English Learners, Special Education, 504 Plan, Gifted and Talented Education (GATE)

or has any special medical conditions please provide the CELDT testing document, IEP, doctor’s note, or any other documentation that supports program participation. You will need to provide copies of all documentation for program participation.

□ Registration Form: Colton Joint Unified School District Registration Required A Colton Joint Unified School District Registration Form is required to enroll your child. Please complete this form by

printing carefully using black ink. It is important that all information included on the form is accurate and legible.

□ Federal Race and Ethnicity Data Collection Required The U.S. Department of Education requires all states to collect information on the race and ethnicity of public school

students and staff.

□ Parent Letter Regarding Parent Education Level Form Required The State Standardized Testing and Reporting (STAR) Program requires each school to provide demographic

information to make accurate comparisons between schools in California. Parent education level is one component the state requires schools to collect as part of this program. This data is an important component used in configuring each school’s Academic Performance Index (API).

□ Electronic Information Resource User Contract Required When signed, this document becomes a legally binding contract outlining the acceptable use of technology, network

privileges, etiquette and privacy. This document needs to be signed by the parent and the student.

□ CAIR Letter Required This information will be used to assist us in determining whether or not your child has received the appropriate

immunizations for school entry and allow the county to notify you when immunizations are due.

□ Overflow Letter Required Your signature on this form is to acknowledge that you understand our policy regarding overflow and that your child

may be placed at an overflow school and then moved to the home school as space becomes available.

□ Report of Health Examination for School Entry (1st grade) Required The State of California requires all children to have a physical examination no sooner than 18 months before entering

first grade. This exam is to find any health problems, prevent future health problems, and to provide children with medical care if needed. Parents have the option of taking their child to a private physician or the Department of Public Health. Parents using public health facilities should be aware that physicals given within 18 months of entering first grade or 90 days after entry are free to those meeting the low-income requirements. Please contact the Department of Public Health at 1-800-722-4794 for further information.

□ Vision Examination (1st grade) Recommended It is recommended that each child have a professional eye examination when he/she enters school and at intervals

thereafter, as recommended.

□ Oral Health (1st grade) Required Education Code now requires your child to have a dental check-up by May 13, 2013, in Transitional Kindergarten,

Kindergarten, or 1st grade whichever is your student’s first year in public school.

□ General Release Form Required Authorization for CJUSD and other communication and media outlets to use photographs/images of students for

educational purposes.

□ Emergency Card Required A Student Emergency Card is required to enroll your child. Please complete this form by printing carefully using black

ink. It is important that all information included on the Student Emergency Card is accurate and legible. Please list your emergency contacts in order of importance.

COLTON JOINT UNIFIED SCHOOL DISTRICT STUDENT REGISTRATION Grades TK – 12 Has your student ever attended school in the Colton Joint Unified School District? Yes No Student ID:

PLEASE PRINT BELOW – STUDENT’S LEGAL NAME (name as it appears on the birth certificate)

Legal Last Name Legal First Name Legal Middle Name (Circle One: AKA Nickname) Grade:

Male Female

Student’s Birth City: Birth State: Birth Country: Mother’s Last Name: (Circle One: Mother Step Mother Guardian)

First Name:

Phone:( )

Home Address:

Apt #:

City:

State: Zip:

Mother’s Employer:

City:

Work Phone:( )

Father’s Last Name: (Circle One: Father Step Father Guardian)

First Name

Phone:( )

Home Address:

Apt #

City

State: Zip:

Father’s Employer:

City:

Work Phone:( )

Mailing Address: (If different than home address)

Apt #

City

State: Zip:

1. Parent/Guardianship Information (with whom the student lives) – check all that apply. Father Mother Both Step-Father Step-Mother Guardian Foster/Group Home Other _______________________________________ 2. Is the above (checked) person (s) the student’s LEGAL guardian? Yes No If No, please complete a “Caregiver Affidavit”. 3. If there is a legal custody agreement or court order regarding this student, please check one. Joint Custody Sole Custody Guardian Court Order Who has legal/physical custody? ___________________________________________ Note: (Please provide copies of any court orders during time of enrollment.) 4. Does student have a Social/Probation/Welfare Worker? Yes No If yes, Name:_____________________________________________________________________ Phone: (_____) _________________________ 5. Duplicate Mailings-If divorced/separated and joint custody allows duplicate mailing information to be given to other parent, please complete their information below. Name:____________________________________________________________ Mailing Address:____________________________________________________ City: ________________________________________________State:_____________________Zip:____________ Phone: (_____) _________________________ Has your student ever been suspended? Yes No Has your student ever been expelled? Yes No Is your student currently under an expulsion order, or been recommended for expulsion from a previous school district(s)? Yes No Has Student Been Retained? Yes No If Yes, Grade Level:________ Year:__________ School:__________________________________

Please complete form using BLACK ink and answer ALL questions.

Age: Birth Date:

Home Cell

Home Cell

Cell

Cell

Office Use Only

HOME LANGUAGE SURVEY: Indicate only one language (most frequently used) per line. 1. Which language did your son/daughter learn when he or she began to talk?_________________________________________________________ 2. Which language does your son/daughter most frequently use at home? ____________________________________________________________ 3. Which language do you use most frequently to speak to your son/daughter?_________________________________________________________ 4. Name the language in the order most often spoken by the adults at home.__________________________________________________________ 5. In which language do you wish to receive communications from the school? English Spanish

Is your student participating in any of the following programs? If yes, please check those that apply below:

Special Education _____ Resource Specialist (RSP) _____ Special Day Class Mild Moderate (SDC MM) _____ Special Day Class Moderate Severe (SDC MS) _____ Adaptive Physical Education (APE) _____ Visually Impaired Program _____ Speech/Language Program _____ Other (Please list) Date of Last IEP:___________________________________________ (Please provide a copy of most recent IEP)

Program Participation _____ Structured English Immersion (SEI) (Level _________) _____ English Language Mainstream (ELM) (Level _________) _____ Initial Fluent English (I-FEP) _____ Redesignated Fluent English Proficiency (R-FEP) LAC Testing Date:________________________________________ _____ Gifted and Talented Education (GATE) _____ AVID _____ Designated 504 Plan

Previous Schools Attended: Please list any schools your student attended previously, beginning with the most recent: School: ____________________ District/City__________________ State:_____ Dates Attended:____/____/_____ to ____/____/_____ Grade:_____ School: ____________________ District/City__________________ State:_____ Dates Attended:____/____/_____ to ____/____/_____ Grade:_____ School: ____________________ District/City__________________ State:_____ Dates Attended:____/____/_____ to ____/____/_____ Grade:_____ School: ____________________ District/City__________________ State:_____ Dates Attended:____/____/_____ to ____/____/_____ Grade:_____

I certify that the information provided is true and correct. Parent(s)/Guardian Signature:______________________________________________________________________ Date:_____________________

Office Use Only

School No.___________ Student ID#_______________________ Enrollment Date:__________________________ CALWorks: Yes No

Retained:_________ Grade: ________ Year: __________ - ____________ Date CUM Requested:_______________________________________

Please Specify: Magnet:____________ Overflow:____________ Inter District Transfer :_______________ Intra District Transfer:_____________ Home School/District:__________________________________________ to: ________________________________________________________ Immunization Complete: Yes No Waiver: Yes No First Grade Physical Date:_______________________ Waiver: Yes No

Birth Certificate Verification: Yes No _____________________________________ Document #:____________________________________

Class Assignment: 1st Semester: ________ 2nd Semester: ________ Year: ____________

Course Number Section Number Grade Level Teacher Room Number

Counselor Signature: ________________________________________________________________ Date: ________________________________ Enrollment Staff Signature: ____________________________________________________________ Date: ________________________________ Notes:

D-129 Revised 12/2015

Federal Race and Ethnicity Data Collection

The U. S. Department of Education requires all states to collect information on the race and ethnicity of public school

students and staff. The federal government has developed a new way to report ethnicity and race that includes new

categories. The changes should provide a more accurate picture of the nations’ ethnic and racial diversity. It will also

enable individuals to be identified in more than one racial category. Please assist us in meeting this state requirement

by answering the two questions below.

1. Ethnicity - Is this student member Hispanic or Latino: (Select only one)

� No, not Hispanic or Latino

� Yes, Hispanic or Latino

The above part of the question is about ethnicity, not race. No matter what you selected above, please continue

to answer the following by marking one or more boxes to indicate what you consider your race to be.

2. Race - What is the race of this student?

� Black or African American

� White

� American Indian or Alaska Native

� Asian Indian

� Asian-Other

� Cambodian

� Chinese

� Japanese

� Korean

� Laotian

� Vietnamese

� Filipino

� Guamanian

� Hawaiian

� Other Pacific Islander

� Samoan

� Tahitian

Colton Joint Unified School District Jerry Almendarez, Superintendent

2016-2017 School Year

Dear Parent or Guardian, The California Longitudinal Pupil Achievement Data System (CALPADS) requires each school to provide demographic information to meet compliance requirements delineated in the No Child Left Behind (NCLB) Act of 2001. Parent education level is one component the state requires schools to collect as part of this program. This data is an important component used in the figuring each school’s Academic Performance Index (API). This information will be kept strictly confidential and will only be used to complete the state required reports. Please provide the information below and submit this form with your registration packet. We appreciate your help in this matter.

Sincerely,

Jerry Almendarez, Superintendent Colton Joint Unified School District ----------------------------------------------------------------------------------------------------------------------------------

Please print the name of your son/daughter: ___________________________________________________________ In the boxes below, indicate the highest education level achieved by each parent or guardian of this student:

Name of Parent/Guardian Completing This Form (please print) ___________________________________________

Parent/Guardian’s Signature _______________________________________________ Date: _____/_____/_____

Please advise school site administration of any changes to the above information.

Mother’s Education Level

___ Not a high school graduate ___ High school graduate ___ Some college (this does not include vocational or

Technical Certification) ___ College graduate (this means graduation with a

B.A. or B.S. degree or an equivalent degree from a foreign university)

___ Graduate school/post graduate training ___ Decline to state or unknown

Father’s Education Level

___ Not a high school graduate ___ High school graduate ___ Some college (this does not include vocational

or Technical Certification) ___ College graduate (this means graduation with a

B.A. or B.S. degree or an equivalent degree from a foreign university)

___ Graduate school/post graduate training ___ Decline to state or unknown

Colton Joint Unified School District

Electronic Information Resource User Contract

D-33A (Revised 5/08)

Student’s Name: ______________________________________________Student # ___________ Grade _______ (please print) last name first name

We believe in the educational value of such electronic services and recognize the potential of such to support curriculum and student

learning. Our goal in providing this service is to promote educational excellence by facilitating resource sharing, innovation, and

communication. We will make every effort to protect students and teachers from any misuses or abuses as a result of their

experiences with an information service. All users must be continuously on guard to avoid inappropriate and illegal interaction with

the information service.

Read this document carefully. When signed by you and your parent/guardian, it becomes a legally binding contract. We must

have your signature and that of your parent/guardian before we can provide you with an access account.

Listed below are the provisions of this contract. If you violate any of these provisions, access to the information service may be

denied and you may be subject to disciplinary action.

Terms and Conditions of This Contract PERSONAL RESPONSIBILITY: I will accept personal responsibility for reporting any misuse of the network to the site

administrator. Misuse can come in many forms, but it is commonly considered as the viewing of any website and/or any message(s)

sent or received that indicate or suggest pornography, unethical or illegal activity, racism, sexism, inappropriate language, threats,

intimidation, sexual harassment and/or bullying of any individual or groups and other issues described below. I understand that all

rules of conduct described in the School Handbook apply when using the network. I understand that there is no implied right to

privacy when using the district system. All electronic communications and downloaded material, including files deleted from a user's

account, may be reviewed by district officials to ensure proper use of the system.

1. Violation of California Education Code 48900 sub-divisions related to computer use will lead to discipline action including loss

of computer, network and/or internet and e-mail privileges suspension, expulsion, or prosecution when appropriate.

2. ACCEPTABLE USE: The use of my assigned account must be in support of education and research. Only educational and

school related business is permitted on the Colton Joint Unified School District’s computers, networks, e-mail accounts and

internet access points. I am personally responsible for this provision at all times when using the electronic information service.

a) Use of other organization's networks or computing resources must comply with rules appropriate to that network.

b) Transmission of any materials in violation of any United States or other state organization is prohibited. This includes, but is

not limited to, copyrighted material, threatening or obscene materials, or materials protected by trade secret.

c) Use of the electronic information services, including the internet, e-mail and school-site/district resources is for educational

purposes only.

d) Use of electronic information services, including the internet, e-mail, and school-site district resources is subject to

monitoring, recording and logging at all times. When using a district computer, network, e-mail account or accessing the

internet, there is no implied right to privacy.

e) Use for commercial activities by for-profit institutions or individuals is not acceptable.

f) Use for product advertisement or political lobbying is also prohibited.

g) I am aware that the inappropriate use of electronic information resources can be a violation of local, state and federal laws

and that I can be prosecuted for violating those laws.

h) All use of the system must be under your own account. Never share your username and/or password with another student. If

you suspect that someone has used your account, report it to a teacher or site administrator immediately. You can and will be

held responsible for any rule violation conducted with your account if you do not report the violation immediately.

3. PRIVILEGES: The use of the information system is a privilege, not a right, and inappropriate use will result in a cancellation of

those privileges. The site administrator, district administrators and district office IT staff will decide what appropriate use is and

his/her/their decision is final. The site administrator or district administrator may close an account at any time deemed necessary.

4. NETWORK ETIQUETTE AND PRIVACY: You are expected to abide by acceptable rules of network etiquette. These rules

include, but are not limited to, the following: a) BE POLITE: Never send, or encourage others to send, abusive messages.

b) USE APPROPRIATE LANGUAGE : You may be alone with your computer, but what you say and do can be viewed globally. Never

swear, use vulgarities, or any other inappropriate language. Illegal activities of any kind are strictly forbidden, and subject to disciplinary

action including suspension and/or expulsion. When using a district computer, network, e-mail account or accessing the internet,

there is no implied right to privacy.

Colton Joint Unified School District

Electronic Information Resource User Contract

D-33A (Revised 5/08)

c) PRIVACY: Do not reveal your or any other student or staff members personal information home addresses, phone numbers, social

security number, or financial information.

d) ELECTRONIC MAIL and INTERNET ACTIVITY: Electronic mail and internet browsing is not private. You are subject to

monitoring, recording and logging of network related activity. Messages relating to or in support of illegal activities must and will be

reported to the authorities.

e) UNAUTHORIZED ACCESS: Do not use the network in any way that would alter, destroy, vandalize, or delete other users or district

files, databases, and/or hardware.

f) DISRUPTIONS: Do not use the computers or any other hardware or software to disrupt access to the network or other electronic

resources.

5. SERVICES: The Colton Joint Unified School District makes no warranties of any kind, whether expressed or implied, for the

service it is providing. The District will not be responsible for any damages including loss of data as a result of delays, non-

deliveries, mis-deliveries, or service interruptions caused by the system or your errors or omissions. Use of any information

obtained via the information system is at your own risk. The District specifically disclaims any responsibility for the accuracy of

information obtained through its services.

6. SECURITY: Security on any computer system is a high priority because there are so many users. If you identify a security

problem, notify the teacher or administrator at once. Never demonstrate the problem to other users. Never use another

individual’s account. All use of the system must be under your own account. Any user identified as a security risk will be

denied access to the information system and face potential discipline consequences.

7. VANDALISM: Vandalism is defined as any malicious attempt to harm or destroy hardware and/or data of another user or any

other agencies or networks that are connected to the system. This includes, but is not limited to, hacking, cracking passwords,

sending junk or unwanted e-mail (SPAM) and the uploading or creation of computer viruses/malware. Any vandalism will result

in the loss of computer services, disciplinary action, and legal referral including suspension and/or expulsion, and the immediate

loss of access to the system.

8. UPDATING: The district will require this Acceptable Use Policy to be signed annually.

9. = = = = = = = = = = Required Signatures = = = = = = = = = =

Student I understand and will abide by the provisions and conditions of this contract. I understand that any violations of the above

provisions will result in disciplinary action, the revoking of my user account, and appropriate legal action. I also agree to report

any misuse of the information system to the site administrator. I understand that misuse can come in many forms, and can be

viewed as any messages sent or received that indicate or suggest pornography, cheating, unethical or illegal solicitation, racism,

sexism, inappropriate language, and/or other issues described above. I understand that all the rules of conduct described in the

School Handbook and regular disciplinary policies apply when I am on the network.

Student’s Signature: ___________________________________________________________ Date: ______________________

Parent or Guardian As the parent or guardian of this student, I have read this contract and understand that network use is designed for educational

purposes. I understand that it is impossible for the Colton Joint Unified School District to restrict access to all controversial

materials, and I will not hold the Colton Joint Unified School District responsible for materials viewed or acquired on the

network. I also agree to report any misuse of the information system to the Colton Joint Unified School District site

administrator. I understand that misuse can come in many forms, but can be viewed as any messages sent or received that

indicate or suggest pornography, unethical or illegal solicitation, racism, sexism, inappropriate language, and other issues

described above. I accept full responsibility for supervision if and when my child’s use is not in a school setting. I hereby give

my permission for my child to be issued an account with access to the internet and e-mail and certify that the information

contained on this form is correct.

Parent/Guardian’s Signature____________________________________________________ Date: ______________________

Colton Joint Unified School District 1212 Valencia Drive, Colton, California 92324 Patricia Carrasco, Enrollment Specialist (909) 580 -6580 Student Services Center Fax: (909) 430 2824

OVERFLOW ACKNOWLEDGEMENT

This form is to acknowledge your child MAY be overflowed. Our district has a 24/1 student to teacher ratio in grades TK-3 and 30/1 in grades 4-6. When classrooms reach their maximum capacity it is necessary to temporarily change student placement until room becomes available at the home school. If your student is overflowed, we will arrange transportation if it is beyond the 1.5 mile walking distance. Your student will be placed on a waiting list in the order of enrollment and called back to the home school when space becomes available. If your student remains at the overflow site the entire school year, he/she will be sent back to the home school for the new school year. If you want your student to remain at the overflow site, you must complete an Intra District transfer during the open enrollment period (March 1st – April 15th). Intra District Transfer approvals are not guaranteed and approved based on space availability. Placement at the home school is not guaranteed. Although we do our best not to separate siblings, there is a possibility all children may not be placed at the same school. Your signature on this form is to acknowledge that you understand our policy regarding overflow and that your child may be placed at an overflow school, then moved to the home school as space becomes available. _________________________________________ __________________ Parent / Guardian Signature Date

AVISO DE POSIBLE UBICACIÓN EN OTRA ESCUELA POR FALTA DE CUPO La presente le informa que es POSIBLE que su hijo tenga que ser asignado a otra escuela por falta de cupo en la propia. CJUSD observa el límite de 24 alumnos por 1 maestro en los grados TK a 3º y 30 a 1 de 4º a 6º. Cuando los grupos llegan al límite de cupo, tenemos que temporalmente modificar la asignación escolar del alumno hasta que haya cupo en la escuela asignada a su domicilio. Si este es el caso de su hijo, y su escuela temporal está a más de 1.5 millas haremos los arreglos necesarios de transporte. El nombre del alumno se pone en lista de espera en el orden que se procesó su inscripción; en cuanto haya cupo se le llama para que asista a su escuela. Si su hijo permanece en la escuela temporal todo el ciclo escolar, se le asigna a su escuela correspondiente para el nuevo año escolar. Si prefiere que su hijo se quede en la escuela temporal, tendrá que llenar una solicitud de transferencia intra distrito durante el período de aceptación de solicitudes: 1º de marzo – 15 de abril. La aprobación de la transferencia intra distrito no se garantiza; se aprueba de acuerdo al cupo disponible. No podemos garantizarle inscripción en la escuela asignada a su domicilio. A pesar de que hacemos lo posible por no separar a hermanitos, existe la posibilidad de que nos sea imposible asignarlos a la misma escuela. Al firmar, indica usted que esté enterado sobre nuestros procedimientos cuando hay falta de cupo y que si su hijo fuera temporalmente asignado a otra escuela, se le llamará para que asista a su propia escuela en cuanto haya cupo disponible. ____________________________________________ _____________________ Firma del padre de familia / tutor Fecha

1212 Valencia Drive, Colton, CA 92324-1798 – (909) 580-5000

Colton Joint Unified School District  Jerry Almendarez, Superintendent                         

Mike Snellings, Assistant Superintendent, Educational Services Division   

Janet Nickell , Director of Pupil Personnel Services   

Dear Parent or Guardian,

The Colton Joint Unified School District is pleased to be able to share your child’s immunization and other health–related information with the CAIR California Immunization Registry Program administered by the San Bernardino County Department of Public Health and the Riverside County Public Health Department. This information will be used to assist us in determining whether or not your child has received the appropriate immunizations for school entry, and allows the county to notify you when immunizations are due.

The attached document provides information about the CAIR Program, along with a list of the data that may be shared. Please note that we are required by law to keep this information confidential.

Please take a moment to review and sign in the indicated area at the bottom of the attached information document, and return it to your child’s school, before the end of the first week of school.

Thank you for your cooperation and understanding. If you have any questions about this program, please contact Health Services (909)580-5002.

Sincerely,

Janet Nickell Director, Pupil Personnel Services

 

 

 

 

 

 

 

 

 

 

 

 

 

1212 Valencia Drive, Colton, CA  92324‐1798 – (909) 580‐5000 

Permission to Share Your Child’s School Immunization/Tuberculosis (TB) Screening Test Information with the California Immunization Registry (CAIR)

Immunizations or ‘shots’ prevent serious diseases. Tuberculosis (TB) screening tests help to determine if you have may have TB infection and can be required for school entry. Keeping track of your child’s shots/TB tests can be hard, especially if more than one doctor gave them. The California Immunization Registry (CAIR) is a secure computer system that doctors and authorized health care providers use to keep track of your child’s shots and TB tests. If you change doctors, your new doctor can use the registry to see your child’s shot/TB test record. CAIR is supported by the California Department of Public Health.

How does CAIR help you? • Keeps track of all your child’s shots and TB tests (skin tests/chest x‐rays), so he/she doesn’t miss any or get too many • Gives you a copy of your child’s most up‐to‐date shot/TB test record (from the doctor) • Helps child care or school officials confirm that your child got shots/TB tests needed to start child care or school • Helps your doctor send you reminders when your child needs shots

How does CAIR help your school? Under California law, schools, child care, and other agencies may use CAIR only to: • See which shots/TB tests children in their programs have received or need • Make sure children have all shots/TB tests needed to start child care or school

What information can be shared in CAIR? • Your child’s name, sex, birth date, and birthplace • Parents’ or guardians’ names • Details about your child’s shots/TB tests, such as type of vaccine/TB test and date given • Limited non‐medical information to correctly identify your child Your child’s information is safe! What’s entered in CAIR is treated like private medical information. Under California law, only your doctor’s office, health plan, or public health department may see your address and phone number. Misuse of the registry can be punished by law.

Parent and Guardian Rights It’s your legal right to: • Say no, if you don’t want to share shot/TB test information from your child’s school record with CAIR • Change your mind later if you want to stop or start sharing your child’s shot/TB test information with CAIR • Look at a copy of your child’s shot/TB test record in CAIR and ask your doctor to correct any possible mistakes • Know who has looked at your child’s CAIR record

If you want to allow your school to share information from your child’s school record with the California Immunization Registry, please SIGN and DATE below. Your child’s school will do the rest!

Parent/Guardian Signature Today’s Date

_/ _/ / Child’s Birth Date (MM/DD/YYYY)

Child sex: M F

Child’s Full Name (please print)

Mother’s First and Last Names (please print) (circle)

If you DO NOT want your child’s shot/TB test records shared with CAIR, do nothing. You’re all done. For more information, contact the CAIR Help Desk at 800‐578‐7889 or CAIRHelpDesk@cdph.ca.gov

California Department of Public Health 10/12

State of California—Health and Human Services Agency Department of Health Care Services Child Health and Disability Prevention (CHDP) Program

 

REPORT OF HEALTH EXAMINATION FOR SCHOOL ENTRY To protect the health of children, California law requires a health examination on school entry. Please have this report filled out by a health examiner and return it to the school. The school will keep and maintain it as confidential information.

PART I TO BE FILLED OUT BY A PARENT OR GUARDIAN CHILD’S NAME—Last First   Middle BIRTH DATE—Month/Day/Year

ADDRESS—Number, Street City ZIP code SCHOOL

PART II TO BE FILLED OUT BY HEALTH EXAMINER

HEALTH EXAMINATION IMMUNIZATION RECORD NOTE: All tests and evaluations except the blood lead test must be done after the child is 4 years and 3 months of age.

Note to Examiner: Please give the family a completed or updated yellow California Immunization Record. Note to School: Please record immunization dates on the blue California School Immunization Record (PM 286).

PART III ADDITIONAL INFORMATION FROM HEALTH EXAMINER (optional) and RELEASE OF HEALTH INFORMATION BY PARENT OR GUARDIAN

If your child is unable to get the school health check-up, call the Child Health and Disability Prevention (CHDP) Program in your local health department. If you do not want your child to have a health check-up, you may sign the waiver form (PM 171 B) found at your child’s school.

PM 171 A (09/07) (Bilingual) CHDP website: www.dhcs.ca.gov/services/chdp

RESULTS AND RECOMMENDATIONS I give permission for the health examiner to share the additional information about the health check-up with the school as explained in Part III.

Fill out if patient or guardian has signed the release of health information.Please check this box if you do not want the health examiner to fill out Part III.

Examination shows no condition of concern to school program activities.

Conditions found in the examination or after further evaluation that are of importance to schooling or physical activity are: (please explain)

Signature of parent or guardian Name, address, and telephone number of health examiner

Date

Signature of health examiner Date

VACCINE

DATE EACH DOSE WAS GIVEN First Second Third Fourth Fifth

POLIO (OPV or IPV)          DtaP/DTP/DT/Td (diphtheria, tetanus, and [acellular] pertussis) OR (tetanus and diphtheria only)

         

MMR (measles, mumps, and rubella)      HIB MENINGITIS (Haemophilus Influenzae B) (Required for child care/preschool only)

         

HEPATITIS B        

VARICELLA (Chickenpox)      

OTHER          

OTHER          

REQUIRED TESTS/EVALUATIONS DATE (mm/dd/yy)Health History /_ /

Physical Examination /_ /

Dental Assessment /_ /

Nutritional Assessment /_ /

Developmental Assessment /_ /

Vision Screening /_ /

Audiometric (hearing) Screening /_ /

Tuberculin Test (Mantoux/PPD) /_ /

Blood Test (for anemia) /_ /

Urine Test /_ /

Blood Lead Test /_ /

Other /_ /

COLTON JOINT UNIFIED SCHOOL DISTRICT

VISION EXAMINATION

Parents/Guardians: It is recommended that each child have a professional eye examination when

he/she enters school and at intervals thereafter, as recommended.

STUDENT’S NAME ________________________________________ DATE _____________

ADDRESS ____________________________________________________________________

SCHOOL _________________________ GRADE _________ PHONE ___________________

EXAMINER:

The school will appreciate a report from you and any recommendations you desire to make. This

information will be of help in planning the educational program for this child.

EXAMINER’S REPORT TO THE SCHOOL

Visual Acuity Glasses

Without Lenses With Lenses _____ Not Prescribed

Right 20/_____ Right 20/_____ _____ Prescribed

Left 20/ _____ Left 20/ _____ _____ To be worn for close work only

Both 20/ _____ Both 20/ _____ _____ To be worn for distance only

_____ Safety Lenses

Preferential seating recommended: ____________________________________________________

Special materials that would be helpful: ________________________________________________

Other recommendations or suggestions: ________________________________________________

Date patient should return for further examination: _______________________________________

Examiner’s Signature _____________________________________ Date ____________________

Address: ________________________________________________________________________

NOTE TO EXAMINER: Please return this completed form to the parent to return to school.

Colton Joint Unified School District Health Services  909‐580‐5002 

 

   

    Joining Together to Go the Extra Mile Dear Parent or Guardian: To make sure your child is ready for school, Education Code now requires that your child have a dental check-up by May 13, 2016 in either kindergarten or first grade, whichever is his or her first year in public school. Assessments that have happened within the 12 months before your child enters school also meet this requirement. The law specifies that the assessment must be done by a licensed dentist or other licensed or registered dental health professional. Take the attached form to the dentist. If you cannot take your child for this required assessment, please indicate the reason for this in Section 3 of the form. California law requires schools to maintain the privacy of students’ health information. Your child’s identity will not be associated with any report produced as a result of this requirement. The following resources will help you find a dentist and complete this requirement for your child:

1. Medi-Cal/Denti-Cal’s toll-free number is 1-800-322-6384; http://www.denti-cal.ca.gov. For help enrolling your child in Medi-Cal/Denti-Cal, contact your local social service agency at 909-388-0245 or http://www.dhs.ca.gov/mcs/medi-Calhome/CountyListing1.htm.)

2. Healthy Families’ toll-free number is 1-800-880-5305. 3. For additional resources that may be helpful, contact the local public health department at 387-

6280. Remember, your child is not healthy and ready for school if he or she has poor dental health! Here is important advice to help your child stay healthy:

Take your child to the dentist twice a year. Choose healthy foods for the entire family. Fresh foods are usually the healthiest foods. Brush teeth at least twice a day with toothpaste that contains fluoride. Limit candy and sweet drinks, such as punch or soda. Sweet drinks and candy also

contribute to weight problems, which may lead to other diseases, such as diabetes. Baby teeth are very important. They are not just teeth that will fall out. Children need their teeth to eat properly, talk, smile, and feel good about themselves. Children with cavities may have difficulty eating, stop smiling, and have problems paying attention and learning at school. Tooth decay is an infection that does not heal and can be painful if left without treatment. If cavities are not treated, children can become sick enough to require emergency room treatment, and their adult teeth may be permanently damaged. If you have questions about the new oral health assessment requirement, please contact your school nurse or our Health Services Office at 909-580-5002.

1212 Valencia Drive, Colton, CA  92324‐1798 – (909) 580‐5000 

Commitment to Equal Opportunity 

Oral Health Assessment Form T07-003, English, Arial Font Page 1 of 1

Oral Health Assessment Form

California law (Education Code Section 49452.8) states your child must have a dental check-up by May 13 of his/her first year in public school. A California licensed dental professional operating within his scope of practice must perform the check-up and fill out Section 2 of this form. If your child had a dental check-up in the 12 months before he/she started school, ask your dentist to fill out Section 2. If you are unable to get a dental check-up for your child, fill out Section 3.

Section 1: Child’s Information (Filled out by parent or guardian)

Child’s First Name:

Last Name: Middle Initial: Child’s birth date:

Address:

Apt.:

City:

ZIP code:

School Name:

Teacher: Grade: Child’s Sex: □ Male □ Female

Parent/Guardian Name: Child’s race/ethnicity: □ White □ Black/African American □ Hispanic/Latino □ Asian □ Native American □ Multi-racial □ Other___________ □ Native Hawaiian/Pacific Islander □ Unknown

Section 2: Oral Health Data Collection (Filled out by a California licensed dental professional)

IMPORTANT NOTE: Consider each box separately. Mark each box. Assessment Date:

Caries Experience (Visible decay and/or

fillings present)

□ Yes □ No

Visible Decay Present:

□ Yes □ No

Treatment Urgency: □ No obvious problem found □ Early dental care recommended (caries without pain or infection; or child would benefit from sealants or further evaluation)

□ Urgent care needed (pain, infection, swelling or soft tissue lesions)

Licensed Dental Professional Signature CA License Number Date

Section 3: Waiver of Oral Health Assessment Requirement To be filled out by parent or guardian asking to be excused from this requirement

Please excuse my child from the dental check-up because: (Check the box that best describes the reason)

□ I am unable to find a dental office that will take my child’s dental insurance plan. My child’s dental insurance plan is:

□ Medi-Cal/Denti-Cal □ Healthy Families □ Healthy Kids □ Other ___________________ □ None

□ I cannot afford a dental check-up for my child.

□ I do not want my child to receive a dental check-up.

Optional: other reasons my child could not get a dental check-up: If asking to be excused from this requirement: ����____________________________________________________

Signature of parent or guardian Date

Return this form to the school no later than May 13 of your child’s first school year. Original to be kept in child’s school record.

The law states schools must keep student health information private. Your child's name will not be part of any report as a result of this law. This information may only be used for purposes related to your child's health. If you have questions, please call your school.

Colton Joint Unified School District Jerry Almendarez, Superintendent

COLTON JOINT UNIFIED SCHOOL DISTRICT

ATTENDANCE POLICY

The mission of the Colton Joint Unified School District is to prepare every student with the knowledge and skills needed for lifelong success in a changing world. Students who are excessively absent from school are not able to accomplish their educational goals. According to the California Compulsory Attendance Law (Ed. Code 48200) students are required to attend school on a regular basis from the ages of 6 to 18 years of age. The District also requires a student enrolled in transitional kindergarten or kindergarten to attend school on a regular basis. Occasionally a student must be absent from school for reasons which are acceptable to the school and the courts, such as illness, medical appointments, or a death in the family. Please either call or send a note to the school following an absence explaining the reason for your child’s absence. The State law states: • Any pupil subject to compulsory education who is absent from school without a valid excuse three

full days or tardy more than any 30-minute period during the school day without a valid excuse on three occasions in one school year, or a combination of each, is considered a truant and shall be reported to the District’s attendance supervisor. (Ed. Code 48260)

• Once a student has received their third truancy, the District will notify the parent/guardian in writing that the student is considered a truant and that the parent/guardian is subject to prosecution if the matter is not corrected. (Ed. Code 48260.5)

District policy states: • Once a student has received six truancies, a second letter will be mailed to the parent/guardian

informing them that their child is truant. The school will also schedule a Student Attendance Review Team meeting (SART) to place the student and parent/guardian on an SART attendance contract. The school will also refer the student and parent/guardian to the District Attorney’s office through the Let’s End Truancy program (LET). Students can also be placed on a SART contract for excessive absences.

• If a student violates the SART contract, the student and parent/guardian will receive a subpoena to attend a Student Attendance Review Board (SARB) to discuss the attendance issues with the Coordinator of Child Welfare and Attendance, the District Attorney, and County Probation. The student and parent/guardian will then be placed on a SARB contract. Violation of the SARB contract will result in the citation of the parent/guardian and/or student with the minimum fine of $100 to a maximum penalty toward the parent/guardian of $2,500 and/or one year in jail. (Penal Code 272)

Feel free to check with the school attendance technician concerning the number of excused or unexcused absences that your child may have. Your cooperation is needed to help us give your student a quality education. If you questions regarding this policy, please contact Christy Padilla at (909) 580-6525.

325 Hermosa Avenue, Colton, CA 92324 – (909) 580-5000 Ext 6525 Commitment to Equal Opportunity

Colton Joint Unified School District Jerry Almendarez, Superintendent

July 2016 Dear Parent or Guardian, The purpose of the student dress and grooming regulations is to maintain a safe and orderly environment, to promote modesty, and to encourage students to dress appropriately and to come to school properly prepared for participation in the educational process. A student may not remain at school or at school activities dressed in a manner which (1) creates a safety hazard for said student or for other students, (2) constitutes a serious or unnecessary distraction to the learning process, (3) tends to disrupt the campus order, or (4) is in conflict with the District's goals and philosophy of the prevention of substance abuse and gang activity. Parents have the primary responsibility to see that students are properly attired for school. School personnel have the responsibility for maintaining proper and appropriate conditions conducive to learning by enforcing District policy. At the Principal’s discretion, school personnel are to enforce all guidelines relating to the following regulations. These guidelines shall be in effect at all school-related activities except where modified by the site administrator for specific extra-curricular activities or specific cases. In case of questionable dress and/or grooming not covered by the guidelines, the site administrator and/or law enforcement personnel will determine the appropriateness and make the final decision. 1. No head coverings are allowed to be worn on school grounds except for sun protective hats that fit the following description: must be plain white, tan, or neutral color canvas with a 2-4 inch brim that follows the entire circumference of the hat. It must be flexible so to fit in a pocket, backpack, purse, book bag or locker. It may not be altered or customized in any way and the chinstrap or strings must match the color of the hat and may not be worn indoors. The hat may include the official school logo. ONLY during inclement weather (as determined by the site principal) may hoods or unadorned beanies be worn outdoors. 2. Clothing, accessories, body art, and/or personal items including, but not limited to, backpacks and folders, shall be free of writing, pictures, or other insignia which are crude, vulgar, profane, or sexually suggestive, which bear weapons, drug, alcohol or tobacco company advertising, promotions, and likeness, or which advocates gang affiliations, ethnic, racial, or religious prejudice. 3. Any clothing or accessory that is a safety hazard to the wearer or others is not allowed. 4. Clothing shall be sufficient enough to conceal undergarments at all times. See-through fabrics, halter tops, tube tops, strapless or off-the-shoulder or low-cut tops, bare midriffs/midsection, and skirts, shorts, or rips in jeans shorter than mid-thigh are prohibited. Sleepwear/loungewear (including but not limited to pajama bottoms and slippers) is prohibited. Excessively baggy pants/shorts, banded or tucked pant leg bottoms, and hanging belt straps are not allowed. Skin must be visible between shorts and knee high socks. 5. Any attire or accessory containing a professional sport team name or logo is prohibited. 6. Students shall be permitted to wear College attire or accessories. 7. Shoes must be worn at all times. For elementary and middle school only: sandals must have heel straps. Flip-flops or backless shoes are not acceptable.

8. Glasses, other than prescription, shall not be worn inside school buildings or outside of buildings if they are a disruption to school activities. 9. Student Identification Badges will be supplied by each Middle School and High School. While on campus during the school day students must have their own ID Badges in their possession and readily available to show when a District staff member requests a student to identify themselves by their ID Badge. The badge may not be defaced or altered in any way (not to be covered by pins, stickers, etc.). Each school will develop their own ID Badge replacement policy; however, a minimal charge will be assessed each time a replacement is issued. This policy will be published and made known to parents and students through their handbook or other means of communication. The students who have financial difficulty will be offered alternatives to this charge. These guidelines shall be in effect at all school-related activities except where modified by the site administrator for specific extra-curricular activities or specific cases. First Offense 1. Verbal warning and counseling, students will change into acceptable clothing. 2. Parent notification. 3. Written documentation of incident. Second Offense 1. Possible one-day in-school suspension, or lunch/recess/after school detention, or warning. 2. Parent notification. 3. Written documentation of incident. Third Offense 1. Possible suspension, in-school or off-campus. 2. Parent conference. 3. Written documentation of incident. Further violations will result in further disciplinary action. Education Code 48900 (k): “Disrupted school activities or otherwise willfully defied the valid authority of supervisors, teachers, administrators, school officials or other school personnel engaged in the performance of their duties.” If any provision of this policy or administrative regulation is held to be invalid or unenforceable by the final decision of a court or competent jurisdiction, all remaining provisions shall remain in full force and effect. Sincerely,

Jerry Almendarez Superintendent

1212 Valencia Drive, Colton, CA 92324-1798 – (909) 580-5000 Commitment to Equal Opportunity

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 13-17 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 120325-120380; California Code of Regulations, Title 17, Division 1, Chapter 4, Subchapter 8, Sections 6000-6075

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

San Bernardino County Department of Public Health

IMMUNIZATION CLINICS For an appointment at any site, please call:

1‐800‐722‐4777

San Bernardino Public Health

799 E. Rialto Ave.

Ontario Public Health

150 E. Holt Blvd.

Victor Valley Public Health

16453 Bear Valley Rd., Hesperia

Barstow Public Health 303

E. Mountain View Ave.

Needles Public Health

1406 Bailey St., Suite D

California Vaccines for Children (VFC) Program Children eligible to receive VFC must be 18 years of age or younger and:

• Be eligible for Medi‐Cal or CHDP; or • Have no insurance; or • Are American Indian or Alaskan Native

Children covered by Healthy Families are not eligible for the VFC Program at this time.

There is an administration fee of $10.00 per shot or oral dose, based on ability to pay. No child is turned away if they cannot pay. Parent or other responsible adult needs to bring shot records, identification,

and the child’s Medi‐Cal card (if you have one).

If you have health insurance or a regular health care provider, please contact them for immunization services.

12/08/15

Please bring your child’s

yellow immunization

card if you have one.

Terrace View is a Visual and Performing Arts Magnet School All Students participate

in a grade level per-formance.

Students also partici-pate in a variety of enrichment projects on visual and performing arts.

For information contact the school (909)580-5016

Magnet Program appli-cations will be accepted at Student Services from March 1 - April 15, 2016.

Ruth Grimes offers Two-Way

Language Immersion Program

Students learn both Spanish and

English languages.

Students start with 90:10 Spanish :

English in kindergarten and

transition to 50:50 by fourth grade.

Research shows that students who

learn two languages excel

academically and are better

prepared for the Globalized World

of 21st Century.

For more information contact the

school (909)-580-5030

Language Immersion applications

will be accepted at Ruth Grimes

Elementary and does not have an

application deadline.

Applications and brochures for both programs are available at CJUSD elementary school sites or Student Services Department

located at 325 N. Hermosa Avenue, Colton (909) 580-6580

Magnetic

Attraction

Terrace View

Elementary:

Visual &

Performing Arts

School

Two–Way Language Immersion Program: Ruth Grimes Elementary School

COLTON JOINT UNIFIED SCHOOL DISTRICT

GENERAL RELEASE FOR

COMMUNITY ACCESS CABLEVISION, NEWSPAPER, PHOTOGRAPHS, VIDEOTAPING, INTERNET WEBSITE

Occasionally, newspaper, magazine, television and video agencies request permission to Photograph students for school or education related issues. Videos or photographs may also be taken by the Colton Joint Unified School District personnel or organizations working in partnership with the District to illustrate District generated news and brochures. These news items and brochures may be shared with news media, posted on the District’s Internet Website or used on district “social media” platforms including, but not limited to, Facebook and Twitter. Such photography or videotaping is done for news purposes only and is not for commercial use.

All photography or videotaping is done by legitimate news media personnel or school district personnel. Your child’s photo/work could possibly be posted to our Internet web page or social media platforms.

Please complete the following information and return before .

Yes My child has permission to be photographed or videotaped for educational purposes including but not limited to classroom projects and to be used on the District website, District network, School website, public newspapers, School newsletters, teacher websites or learning management systems, and district associated social media sites

No My child does not have permission to be photographed or videotaped for use on publicly accessible platforms including District website, School website, public newspapers, School newsletters, teacher websites or learning management systems, and district associated social media sites.

Student Name: (Please PRINT)

Parent/Guardian Signature:

Date:

Date:

D-120-WEB

COLTON JOINT UNIFIED SCHOOL DISTRICT Student Emergency Card

Student’s Name

_____________________________________________________ Last Name First Name Middle Name

Home Phone(___) _________________ Birth Date ____________ Unlisted Address ______________________________________________ City _________________________________ Zip ____________

Mother’s Name _________________________________________

(Circle One: Mother, Step Mother, Guardian)

Address ______________________________________________ City __________________________________ Zip ___________ Home Phone(___) ______________ Cell(___) ________________ Unlisted

Place of Business ______________________________________ Work Phone (___) __________________________ Ext. ________ E-mail Address ________________________________________

Father’s Name __________________________________________

(Circle One: Father, Step Father, Guardian)

Address ______________________________________________ City __________________________________ Zip ___________ Home Phone(___) ______________ Cell(___) ________________ Unlisted Place of Business ______________________________________ Work Phone (___) __________________________ Ext. ________ E-mail Address ________________________________________

Names of Brothers and Sisters in District and/or in the Home: ________________________School_________DOB___/___/____ ________________________School_________DOB___/___/____ ________________________School_________DOB___/___/____ ________________________School_________DOB___/___/____

Grade ___________ Student ID _______________________ (Office use only) School__________________________________Date_________________ Emergency Contacts: Responsible persons, other than yourself, who can pick up or be called in case of an emergency or disaster (18 years or older):

1. First/Last Name ____________________________________________

Relationship ________________________Phone(____) _____________ (Circle One: Home Work Cell)

2. First/Last Name ____________________________________________

Relationship ________________________Phone(____) _____________

3. First/Last Name ____________________________________________

Relationship ________________________Phone(____) _____________

(Circle One: Home Work Cell)

4. First/Last Name ____________________________________________

Relationship ________________________Phone(____) _____________

(Circle One: Home Work Cell)

Family Doctor ________________________________________________ Address ____________________________________________________ City ____________________ Daytime Phone (____) _________________

Health Plan/Insurance Co. ________________________________________ Group/Policy #_______________________________________ None

Medical History: My Child is allergic to the following medications/food/insect bites:

___________________________________________________________________________________________________________________________________________________

My Child takes the following medications at home:

_____________________________________________________________________________________________________________________________________________________

My Child takes the following medications at school:

___________________________________________________________________________________________________________________________________________________

My Child has the following health problems:

___________________________________________________________________________________________________________________________________________________

My Child has no medical issues: Parent Initials: _______________________

(Circle One: Home Work Cell)

I OBJECT to the release of student information. I DO NOT OBJECT to the release of student information.

As legal custodian of _____________________________________________, a minor, I hereby authorize the principal or his/her designee, into whose care the aforementioned minor pupil has been entrusted, to consent to any X-ray, examination, anesthetic, medical or surgical diagnosis, treatment, and/or hospital care to be rendered to said minor upon the advice of any licensed physician and/or dentist. I understand that this authorization is given in advance of any required diagnosis, treatment, or hospital and provides authority and power to the aforementioned agent(s) to give specific consent to any and all such diagnosis, treatment, or hospital care which a licensed physician or dentist may deem necessary. This authorization shall remain effective for the full school year unless revoked in writing and delivered to said agent(s). I understand that the Colton Joint Unified School District, its employees and its Board assume no liability of any nature in relation to the transportation or treatment of said minor. I further understand that all costs of paramedic transportation, hospitalization, and any examination, X-ray, or treatment provided in relation to this authorization shall be my responsibility.

Signature of Parent or Guardian_________________________________________________________________________________ Date_________________________________ D-81 Revised 04/14/16

Parents Rights hI have read the information on this form and understand its content. My signature verifies that I have been informed of my rights as a parent/guardian of a public school student. My

signature DOES NOT indicate consent to participate in a particular program. I will send written notice to the school of any specific objections I have regarding my student’s participation in a particular program or service. I understand that the health information may be shared verbally or in writing with school district personnel. Signature of Parent or Guardian_________________________________________________________________________________ Date_________________________________

I understand that the Colton Joint Unified School District does not provide accident medical insurance for students for school related injuries but does offer student accident insurance for voluntary purchase. I have received the information and application for this program.

Please Check One: I will enroll my child in the program I will not enroll my child in the program.

Signature of Parent or Guardian_________________________________________________________________________________ Date_________________________________

Where is your child/family currently living? (check one box only) This information will be used to determine if your child qualifies for additional assistance under the “No Child Left Behind Act of 2001”. In a single family residence With more than one family in a house or apartment due to economic hardship. Living with Others (Caregiver Affidavit) In a shelter or transitional housing program In a motel/hotel Temporarily unsheltered (car, camp site, etc) In a foster care placement or group home

(Complete all sections below)

Colton Joint Unified School District

2016-2017 School Calendars Elementary Schools

Middle and High Schools

JULY 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

H

H

NOVEMBER 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

M M H M R R R H H M

H R R R H H

MARCH 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

M M ▲ ▲ ▲ R R R R R R R R R R

R R R R R R R R R R

March 17 Quarter 3=46

Students do not attend school:

* Teacher Preparation Days C = LCAP Teacher Collaboration Days

R = Recess days

Holidays September 5 Labor Day

November 11 Veterans’ Day November 21-25 Thanksgiving Break December 19-January 9 Winter Break January 16 Martin Luther King, Jr. Day

February 13 & 20 Presidents’ Days March 20 - March 31 Spring Break

May 29 Memorial Day

AUGUST 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

* C * M M M M

* C *

DECEMBER 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

M M * R R R H H H R R R H

M M M * R R R H H H R R R H

December 15 Quarter 2 & Semester 1=88

APRIL 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

M M M M

▲ ▲ ▲ ▲ ▲

Grades 7-12 Finals

December 13-15 June 1, 2, 5

CAASPP (Common Core Testing)

Grades 3-8 March 1 to the end of the year

Grade 11 April 24 to the end of the year

SEPTEMBER 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

H M M M M

H

JANUARY

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

H R R R R C M H M M

H R R R R C H

MAY

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

M M M M H M

H

June 6 Quarter 4=46 &

End of Quarter and Semester Dates Quarter 1 – October 7

45 days Quarter 2/ Semester 1 - December 15

43 days Quarter 2 88 days Semester 1

Quarter 3 - March 17 46 days

Quarter 4/Semester 2/End of year June 6 46 days Quarter 4

92 days Semester 2

Report Cards 7-12 Quarter

K-12 Semester

OCTOBER 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

M ▲ ▲ ▲ ▲ ▲ M M

▲ ▲ ▲ ▲ ▲

October 7 Quarter 1

FEBRUARY

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

M M H M H M

H H

JUNE

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

M

M M M M

Semester 2=92

Minimum Days ▲ K-8 Parent and Teacher Conferences

Students attend minimum days M Minimum day - grades K-6 M Minimum day – grades 7-12