January 15, 2014 - Millbrae School District

Transcripción

MILLBRAE SCHOOL DISTRICT
2014-2015 STUDENT REGISTRATION
Registration Dates:
January 15, 2014 – February 21, 2014
TRANSITIONAL KINDERGARTEN
All students who turn five (5) years old between September 2 - December 2, 2014, may
enroll in Transitional Kindergarten for the upcoming 2014-2015 school year.
REQUIRED REGULATION
All 7th & 8th Grade students must have and provide proof of the T-Dap, whooping cough
booster immunization.
Green Hills School
401 Ludeman Lane
Millbrae, CA 94030
(650) 588-6485
Lomita Park School
200 Santa Helena Ave.
San Bruno, CA 94066
(650) 588-5852
Meadows School
1101 Helen Drive
Millbrae, CA 94030
(650) 583-7590
Spring Valley School
817 Murchison Drive
Millbrae, CA 94030
(650) 697-5681
Please contact your home school to schedule registration appointments.
Taylor Middle School
850 Taylor Blvd.
Millbrae CA 94030
(650) 697-4096
THIS PAGE LEFT INTENTIONALLY BLANK
REVISED 1.10.13
STUDENT NAME: ________________________________________
SCHOOL:_____________
GRADE IN 2014-2015____________
ADDRESS:__________________________________________________________________________________________________________
PHONE NUMBER:____________________________
EMAIL:____________________________
TRANSITIONAL KINDERGARTEN □
Registration Document Check-Off List
Place a check mark next to the completed/attached items. All forms must be complete, signed and/or initialed and must be
returned to the school office of your resident school.
PROOF OF RESIDENCY (REQUIRES TWO DOCUMENTS WITH PARENT/GUARDIAN NAME
AND ADDRESS LISTED)
Homeowner or Renter/Lessee:
□ Grant Deed or □ Property Tax Bill or □ Original rental or lease agreement
AND
□ PG&E Bill or PG&E Confirmation of Service or □ Water Dept. bill
Sub-Lease:
□ A letter from the manager confirming sub-lease agreement and confirmation
of residency at that address for registering family.
NEW STUDENT REGISTRATION FORM
PRIMARY LANGUAGE SURVEY
RESIDENCY VERIFICATION AFFIDAVIT
STUDENT RESIDENCY QUESTIONNAIRE
**IF SHARED RESIDENCY:
□ District’s Verification of Shared Residency Form (please request form from school office
if applicable)
□ Proof of Residency documents as required above
STUDENT ORIGINAL BIRTH CERTIFICATE (a copy will be made and original returned to
you.)
STUDENT HEALTH INVENTORY (completed by parent/guardian)
REPORT OF HEALTH EXAMINATION FOR SCHOOL ENTRY/ CURRENT IMMUNIZATION
RECORDS & DATES (completed by physician)
• Current TB Test Results (within the last 12 months) if registering for the first time in a
California Public School (i.e. Students from out of the state or country, or first time
registering in Transitional Kindergarten or Kindergarten)
• Transitional Kindergarten and Kindergarten: Physical Exam AFTER March 1, 2014.
STUDENT Tdap BOOSTER & DATE (7TH & 8TH Grade Students only)
PARENT/GUARDIAN IDENTIFICATION
**IF APPLICABLE – Copy of any supplemental services documents
□ Current 504 Plan
□ Current Individualized Education Program (IEP)
**IF your student is currently being assessed, please attach any related documents (i.e.
Assessment Plan)
For Office Use Only:
Id# _____________School ______________________Grade __________ Teacher __________________________ Room ________Date _________Year ________________
Millbrae School District
2014-2015 New Student Registration Form
2013-2014
_____________________________________ __________________________________ _____ ______________
Student Last Name (Apellido del Estudiante)
Student First Name (Primer nombre del estudiante)
MI
Nickname (Apodo)
_______________________________________________________________________________________________________________________________________________
Address (Domicilio) , City (Ciudad), State (Estado), Zip Code (Codigo postal)
_______________________________________________________________________________________________________________________________________________
Home Phone (Telefono de casa)
Cell Phone (Telefono de cellular)
Birthdate (Fecha de nacimiento)
Gender (Sexo)
Enrolled (Matriculados):
Resident School (Escuela de residencia)
Presently registered at another school?
Shared Residency (Residencia compartida)
(Actualmente inscrito en otra escuela?)
No (No)
Yes (Si)
Intradistrict Agreement (Acuerdo dentro del distrito)
Interdistrict Agreement (Acuerdo entre distrito)
If yes, which one? (En caso afirmativo,cual?) ______________________
Last school attended (Ultima escuela que asistió): _______________________________________________________________________________________________________
Name (Nombre)
City (Ciudad)
State (Estado)
Does your child have an active IEP (Individual Education Plan)? No (No)
Yes (Si)
Tiene el estudiante un plan activo de educacion individual?
Speech/Language (espicho/lenguaje)**
Special Day Class (clase especial de dia) **
Resource (recurso) **
Is your child currently receiving any of the following services? (Please check all that apply)
El estudiante esta recibiendo cual quiera de los siguientes servicios? (Por favor marque todos los que apliquen)
GATE (Educación para Dotados y Talentosos) **
504 Plan**
ELL (aprendices del idioma Ingles) **
Expulsion(expulsión) **
** If you have checked any of these programs, please attach the current 504 Plan or IEP. (Si la respuesta es si por favor adjuntar una copia dela documentacion)**
1. Is student an Immigrant?
(Inmigrante?)
No(No)
Yes (Si)
2. If Immigrant, which country?
(Si inmigrante, que pais?)
4. Date of Entry into CA Public Schools
(Fecha de ingreso en las escuelas publicas de California?)
6. Place of Birth? (Lugar de nacimiento?)
____________________
3. US Entry Date (Date of Immigration)
(Entrado de fecha a los Estados Unidos) ________________________
____________________
Month/Year (Mes/Ano)
5. Date of Entry into US Schools
(Fecha de ingreso en las escuelas de Estados Unidos)_____________
Month/Year
Country ____________________
(Pais)
7. What is your student’s ethnicity? (Please check only one)
(Etnicidad del estudiante?)
Hispanic or Latino (500)
(Hispano o Latino)
City ________________
(Ciudad)
State ________________________
(Estado)
Not Hispanic or Latino
(No Hispano o Latino)
8. What is your student’s race? (Choose one or more)
(Cual es la raza del estudiante?)
American Indian/Alaska Native
Black or African American
White
Asian
Asian Indian
Cambodian
Laotian
Other Asian
Native Hawaiian or Pacific Islander
Guamanian
Hawaiian
Chinese
Filipino
Hmong
Tahitian
Other Pacific Islander
Japanese
Korean
Vietnamese
Samoan
3
PARENT INFORMATION:
(INFORMACION PARA LOS PADRES)
With whom does the student live? (Please check all that apply)
(Conquien vive el estudiante?) (Por favor marque todos los que apliquen)
Mother (Madre)
Father (Padre)
Stepmother (Madrasta)
Stepfather (Padrasto)
Grandparent(s) (Abuelos)
Aunt/Uncle (Tia/Tio)
Shared Custody (Custodia compartida)
Foster Parent(s) (Padres de crianza)
Other (Otro) ____________________
By providing your email address, you are giving permission to receive school and classroom news and information by email.
(Proporcianando su direccion de correo electronico, usted esta dando permiso para recibir noticias de la escuela y salon de clases e informacion por correo electronico.)
FATHER (PADRE)
Natural
Stepfather (Padrasto)
MOTHER (MADRE)
Other (Otro) _______________
Natural
Stepmother (Madrasta)
Other(Otro)_______________
Name
(Nombre)
Name
(Nombre)
Home Address
(Domicilio de casa)
Home Address
(Domicilio de casa)
City, State, Zip Code
(Ciudad, Estado, Codigo postal)
City, State, Zip Code
(Ciudad, Estado, Codigo postal)
Home Phone
(Telefone de casa)
Home Phone
(Telefone de casa)
Cell Phone
(Telefono cellular)
Cell Phone
(Telefono cellular)
Work Phone
(Telefono de trabajo)
Work Phone
(Telefono de trabajo)
E-mail
(Direccion de correo electronico)
E-mail
(Direccion de correo electronico)
Employer
(Empleador)
Employer
(Empleador)
Occupation
(Ocupacion)
Occupation
(Ocupacion)
Education Level
(Nivel de educacion)
High School Graduate (Graduado de la escuela Secundaria)
Education Level
(Nivel de educacion)
High School Graduate (Graduado de la escuela Secundaria)
Not a High School Graduate (No me gradue de la secundaria)
Not a High School Graduate (No me gradue de la secundaria)
College Graduate (Graduado de la Universidad)
College Graduate (Graduado de la Universidad)
Some College or Associate’s Degree (Un poco de Universidad o titulo asociado)
Some College or Associate’s Degree (Un poco de Universidad o titulo asociado)
Graduate Degree or Higher (Titulo de grado o superior)
Graduate Degree or Higher (Titulo de grado o superior)
Declined to State or Unknown (Declinar my respuesta)
Declined to State or Unknown (Declinar my respuesta)
OTHER CHILDREN IN HOUSEHOLD
(Ostros Ninos en la familia)
Last Name
(Apellido)
First Name
(Primer Nombre)
Birthdate
(fecha de nacimiento)
Gender
(Sexo)
School
(Escuela)
4
EMERGENCY/HEALTH INFORMATION:
(IMFORMACION DE EMERGENCIA Y SALUD)
Doctor’s Name
(Nombre del doctor)
________________________________________________________________
Telephone
(Telefono) ______________________________________
Hospital
(Hospital)
________________________________________________________________
Telephone
(Telefono) _______________________________________
Insurance Company
(Compania aseguradora)
Insurance ID #
Plan/Policy #
______________________________________ (Identificacion del seguro) _________________________ (Plan/# de poliza)______________
STUDENT MEDICAL CONDITIONS
(CONDICIONES MEDICAS)
(Check all that apply)
(Todas las que apliquen)
On Medication
(Medicacion)
Yes
(Si)
No
(No)
If yes, name of medication
(Nombre de medicina)
_____________________________________________________________________
Allergies
(Allergias)
Yes
(Si)
No
(No)
If yes, name allergies
(Nombre de allergias)
_____________________________________________________________________
Yes
PE Limitations
(Limitaciones de educacion fisica) (Si)
No
(No)
If yes, name limitation(s)
(Nombre de limitaciones)
_____________________________________________________________________
Please check if the student has any of the following:
(Porfavor compruebe si el estudiante tiene cualquiera de los siguientes:)
Heart Problems (Limitaciones de Corazon)
Seizure Disorders (Ataques)
Asthma (Asma)
Diabetes (Diabetes)
Glasses/Contacts (Lentes/contactos)
Hearing Problems (Problemas de audicion)
Explanations or comments about medical conditions that the school should be aware of:
(Explicaciones o comentarios sobre condiciones medicas que la escuela necesite ser conscientes:)
________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
NOTE: If it is necessary for your child to take medication at school, you must provide the school with the physician’s written instruction and your written
permission. Medication at school must be kept in the original pharmacy container. No medicine of any kind (prescriptions or non-prescriptions drugs including
aspirin or aspirin substitutes) will be given at school unless the above conditions are met.
(NOTA: Si es necesario para que su hijo(a) tome medicina en la escuela, debe proveer a la escuela las instrucciones del medico por escrito y su autorizacion.
Medicamentos en la escuela se debe mantener en el envase original de la farmacia. Ningun medicamiento de cualquier (prescripcion o medicamientos de tipo sin
receta incluyendo, aspirina o sustituto de la aspirina) se dara en la escuela a menos que las condiciones anteriores se cumplen. )
If parents cannot be reached in an emergency, please contact:
(Si los padres no puede ser contactados en caso de emergencia contacten a:)
Name _____________________________________________________Day Time Phone ______________________________________ Relationship_______________________
(Nombre)
(Numero de telefono durante el dia)
(Relacion)
I CONSENT (Doy mi consentimiento)
I DO NOT CONSENT (No doy consentimiento)
For emergency treatment if it is deemed necessary by the school authorities and after all efforts to reach the parent or designated adult have failed. Your son/daughter will be taken
by ambulance at parent’s expense to the nearest emergency facility
(Para tratamiento de emergencia si se considera por las autoridades de la escuela y despues de todos los esfuerzos para localizar a los padres o adulto designado a fracasado. Su
hijo(a) sera llevado por ambulancia “a expensas de los padres” a las instalaciones de emergencia mas cercana.
I WILL NOTIFY THE SCHOOL IF THERE IS A CHANGE IN ANY OF THE INFORMATION ON THIS FORM.
(VOY A NOTIFICAR A LA ESCUELA SI HAY UN CAMBIO EN ALGUNO DE LOS DATOS EN ESTE FORMULANO.)
_____________________________________________________________________________________
Parent/Guardian Signature (firma del padre/madre’guardian)
_____________________________
Date (Dia)
5
Primary Language Survey
California Education Code §52164.1; California Code of Regulations 5CCR 4304
______________________________________________________
Student Name (please print)
_________________________
School
_____________
Grade
A Home Language Survey is required of each newly enrolling student in a California public or non-public school.
Answers of languages other than English on questions 1, 2, or 3 will trigger a state test of English language development. The
purpose is to know the languages and educational needs of students, so we can provide access to the educational program and
rapid fluency in English.
Parents, please answer the following questions:
1. Which language did your child learn when he/she first learned to talk? ________________________________
2. Which language does your child use most frequently at home? _______________________________________
3. Which language do you use most frequently at home? ______________________________________________
4. Which language is most often spoken by the adults in your home? ____________________________________
_______________________________________________________
Parent Signature
______________________________________________________
________________________________
Date
_________________________
School
_____________
Grade
Una encuesta de idioma que se requiere de cada estudiante inscrito recientemente en una escuela pública de California o no
pública.
Respuestas de otros idiomas aparte del Inglés en las preguntas 1, 2, o 3 dará lugar a un examen estatal de desarrollo del
idioma Inglés. El propósito es conocer las lenguas y las necesidades educativas de los estudiantes, por lo que puede
proporcionar el acceso a los programas educativos y rápida fluidez en Inglés.
Instrucciones para padres y tutores:
1.
¿Qué idioma aprendió su hijo cuando empezó a hablar?________________________________________
2.
¿Qué idioma habla su hijo en casa con más frecuencia?________________________________________
3.
¿Qué idioma utilizan ustedes (los padres o tutores) con más frecuencia?
hablan con su hijo?
4.
¿Qué idioma se habla con más frecuencia entre los adultos en el hogar? ________________________________________ (padres,
tutores, abuelos o cualquier otro adulto)?
________________________________________________________
Parent Signature
________________________________________ cuando
____________________________________
Date
6
Primary Language Survey
California Education Code §52164.1; California Code of Regulations 5CCR 4304
______________________________________________________
给家長和監護人的指示：
_________________________
School
_____________
Grade
加利福尼亞州《教育法》(Education Code)
含有法定要求，即各個學校必須確定每個學生在家中使用的口頭語言。本資訊對於各學校提供完善的輔導學
程和服務來說至關重要。
作為家長或監護人，您必須給予配合，以便順利執行這項法定要求。請盡可能準確地回答後述四個問題。請
在每個問題所提供的空白處填寫相應語言的名稱。請勿遺漏任何問題。
1. 您的孩子開始學習說話時學的是哪種語言？________________________________________
2. 您的孩子在家中最常講的是哪種語言？________________________________________
3. 您 (家長或監護人)
在與您的孩子交談中最常使用哪種語言？________________________________________
4. 家裡的成人 (家長、監護人、祖父母或任何其他成年人) ________________________________________
最常講的是哪種語言？
請在下面相應的空白處簽名並註明填寫日期，然後將本表交回給您孩子的老師
_____________________________________
(家長或監護人簽名)
_________________________________
(日期)
7
•
New Students
Millbrae, CA 94030
Residency Verification Affidavit
School _______________________________________
Child’s Name _________________________________ Current grade _____ Birthdate _______________
Child lives with
�Mother
�Father
�Guardian
�Caregiver
Adult’s name
__________________________________________________________________
Address**
__________________________________________________________________
City
__________________________________________________________________
Home Phone
_________________________ Work Phone ______________________________
**If you are not a resident of Millbrae School District,
please inquire in the school office regarding interdistrict transfer requests.
Please read and initial each of the following statements:
The Millbrae School District will actively investigate all cases where it has reason to believe false information has been
provided on District forms and may verify with home visits. _______ (initial)
The District may refer cases in which false information has been intentionally provided to the San Mateo District Attorney for
further action and/or file civil action to recover damages incurred as a result of providing false information. _______ (initial)
Persons who provide false information on a District form are subject to criminal prosecution for perjury which is punishable
by a fine and/or a prison term of up to four years in State prison (Fam. Code §6552; Pen. Code § 118 & 126) _______
(initial)
Persons providing false information on an affidavit also are civilly liable for fraud, negligent misrepresentation, and
negligence. Parties found civilly liable may be required to pay all damages caused to the District as a result of providing
false information, as well as punitive damages. (Civ. Code §1709) _______ (initial)
Persons who induce, obtain or otherwise solicit another person to provide false information on an affidavit are subject to the
same criminal prosecution, fines, and imprisonment as the person directly committing perjury. (Pen. Code §127) _______
(initial)
Investigations that reveal students were enrolled on the basis of providing false information will lead to immediate removal
from the District. _______ (initial)
8
Residency Verification Required
Documentation showing address where living must be current and provided at time of registration before child enters
school:
Homeowners
One of the following:
1. current tax bill with name and address on it
2. current tax receipt with name and address on it
3. deed of trust with name and address on it
AND
1. current PG&E bill with name and address on it
2. current Water bill with name and address on it
Rent or Lease
All of the following:
1. rental/lease agreement with residency’s address, owner/manager’s name and
phone number for verification
2. current PG&E bill or Water bill with name and address on it unless utilities are
included in the rental/lease agreement
Signature of Parent/Guardian ______________________________________ Date _________________
RESIDENCY VERIFICATION
WHEN PARENTS LIVE IN MILLBRAE SCHOOL DISTRICT
All new enrollees will be asked to provide proof of residency. Verification must be presented before the student will be admitted.
Proof of residency may be required of enrolled students upon the request of District administration.
1. Home Ownership: Two of the following must be presented at the time of registration and must have the name/address of the
parent/guardian on it:
a. Deed of Trust
b. Assessor’s bill
c. Property Tax receipt
AND
d. PG & E bill
e. Water bill
2. Home Lease: The person who will be leasing will provide both
a. The lease agreement
AND
b. PG&E bill with his/her name and address or if you haven’t been billed yet, a receipt from PG & E showing transfer of PG&E
services to new address or a water bill.
9
3. Apartment Rent or Lease: The person must provide all of the following:
a. Manager’s name and telephone number
b. Rental/Lease agreement
c. Current PG&E bill with his/her name and address or if not receiving a bill yet, a receipt from PG&E showing transfer of PG&E
services to new address or water bill.
d. If PG&E is included in rental payment, that should be stated in the Lease Agreement.
4. Sub-Lease: The person must provide all of the following:
a. A letter from the manager stating that he/she is aware of the sub-lease agreement and that the registering family does live at
that address under a sub-lease
b. A copy of the sub-lease
c. Manager’s name and telephone number.
5. Sharing a Place of Residence: When parents and student are sharing a home or apartment with Millbrae School District
residents, the following must be provided:
a. A completed “Verification of Shared Residence” form signed by the parent/guardian and property owner/renter indicating that
the registering family does live at that address.
b. When students are enrolling under “Sharing a Place of Residence,” the registered resident must furnish proof of residence as
indicated above.
10
STUDENT RESIDENCY QUESTIONNAIRE
This document is intended to address the McKinney-Vento Assistance Act Title X, Part C of the No Child Left Behind Act.
Your answers will help determine documents necessary to enroll your child quickly.
Student: _________________________________________________________________________________________
Birth date: ___________________________
Grade: ____________ Male _____ Female_____
1. Do you and your student live in a fixed, regular, adequate nighttime residence?
Yes_____ No_____
If you marked “Yes”, stop here. Please skip to Question #4.
If you marked “No”, please continue with this form.
2. Where does the student stay at night?
□in a shelter
□ in a motel/hotel
□ in a car or RV
□ at a campsite
□ transitional housing
□ temporarily with another family in a house, mobile home, or apartment (because the family does not have a place of its
own) * Please meet with principal*
□ other location ________________________________________________________
3. The student lives with:
□ one parent
□ two parents
□ a qualified relative
□ friend(s)
□ an adult that is not the legal guardian
□ alone with no adult(s)
4. I am:
□ the parent/legal guardian of the above-named student
□ a qualified adult relative of the above-named student
(Relationship: _______________________________________________________)
I declare under penalty of perjury under the laws of this state that the information provided here is true and correct and of my own
personal knowledge.
Signature: ___________________________________________________________
Date: __________________
Print Your Name: _________________________________________________________________________________
Residence: ______________________________________________________________________________________
Street
City
Zip
Mailing Address: __________________________________________________________________________________
Street
City
Zip
Telephone: (________) ____________________________ Cell Phone: (________) _____________________________
11
CUESTIONARIO JURADA SOBRE LA RESIDENCIA DEL ESTUDIANTE
La finalidad de este documento es en referencia a la Ley McKinney-Vento para Ayuda a las Personas sin Hogar (McKinney-Vento Assistance
Act). Sus respuestas ayudarán a determinar qué documentos son necesarios para matricular a su hijo con rapidez.
Estudiante: __________________________________________(Marque con un círculo una respuesta: Hombre/Mujer)
Fecha de nacimiento: _______________ Grado:____________
1. ¿Viven usted y su hijo(a) en una residencia regular y fija adecuada para pasar la noche?
Sí
No
Si respondió “Sí”, deténgase aquí.
Si respondió “NO”,continúe llenando el formulario.)
2. ¿Viven usted y su hijo(a) en:
□ refugio
□ motel/hotel
□ automóvil o vehículo recreativo (RV)
□ campamento
□ vivienda de transición
□ temporalmente con otra familia en una casa, casa móvil o apartamento
*Favor de reunirse con el director.
□ otro lugar __________________________________________________
3. El estudiante vive con:
□ uno de los padres
□ los dos padres
□ un familiar calificado
□ amigo(s)
□ un adulto que no es su tutor legal
□ solo, sin ningún adulto
4. Yo:
□ soy el padre/madre o tutor legal del estudiante nombrado anteriormente
□ soy un adulto calificado, familiar del estudiante nombrado anteriormente
(Parentesco: _______________________________)
Declaro, bajo pena de perjurio, de conformidad con las leyes del Estado de California, que la información
anterior es verdadera y correcta y tengo de la misma un conocimiento personal.
Firma: __________________________________________ Fecha: _________
Escriba su nombre en letra de imprenta: ___________________________________
Residencia: ________________________________________________________________
Calle
Ciudad
Código postal
Dirección: ________________________________________________________________
Calle
Nº de teléfono: (
Ciudad
) _______________ Nº de teléfono celular: (
Código postal
) ________________
12
STUDENT REGISTRATION FOR 2014-2015 SCHOOL YEAR
Registration Period: January 15, 2014 – February 21, 2014
Health Exams and Immunizations
Required for Student Enrollment
The following immunizations are now required for Kindergarten and New Students:






4 Polio (3 doses meet requirement if at least one was given on or after 4th birthday)
5 DPT (4 doses meet requirement if at least one was given on or after the 4th birthday)
2nd MMR (one dose must be on or after 1st birthday)
Hepatitis B series (3 shots)
Varicella (chickenpox) Vaccine or proof of the disease
TB Test and Results (within the last 12 months)
All students entering 7th and 8th Grades must have and provide proof of the
whooping cough booster immunization, also called “T-dap.”
(Please see the following page, “Guide To Immunizations Required for School Entry” for additional information.)
KINDERGARTEN and TRANSITIONAL KINDERGARTEN:
Please have your physician perform a complete health examination on your child after March 1, 2014 and return the attached
health examination form to the school office.
GUIDE TO IMMUNIZATIONS REQUIRED FOR SCHOOL ENTRY
Grades K-12
INSTRUCTIONS
Use this guide as a quick reference to help you determine whether children seeking admission to your
school meet California’s school immunization requirements. For the actual laws, see 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. If you have any questions, call the Immunization
Coordinator at your local health department.
IMMUNIZATION
REQUIREMENTS
To enter into public and private elementary and secondary schools (grades kindergarten through 12),
children under age 18 years must have immunizations.
VACCINE
REQUIRED DOSES
Polio
4 doses at any age, but... 3 doses meet requirement for ages 4–6 years if at
least one was given on or after the 4th birthday1; 3 doses meet requirement
for ages 7–17 years if at least one was given on or after the 2nd birthday.1
Diphtheria, Tetanus, and Pertussis
Age 6 years and under: DTP, DTaP or any combination of DTP or DTaP with
DT (diphtheria and tetanus) 5 doses at any age, but... 4 doses meet requirements for ages 4–6 years if at least one was on or after the 4th birthday.1
Age 7 years and older: Tdap, Td, or DTP, DTaP or any combination of these
4 doses at any age, but...3 doses meet requirement for ages 7–17 years if at
least one was on or after the 2nd birthday.1 If last dose was given before the
2nd birthday, one more (Tdap) dose is required.
Measles, Mumps, Rubella (MMR)
Kindergarten: 2 doses2 both on or after 1st birthday.1
7th grade: 2 doses2 both on or after 1st birthday.1
Grades 1–6 and 8–12: 1 dose on or after 1st birthday.1
1
2
3
4
5
6
7
Hepatitis B3
Kindergarten: 3 doses at any age
Varicella
1 dose4, 6
Tdap Booster (Tetanus, reduced
diphtheria, and pertussis)
7th grade: 1 dose on or after 7th birthday. 5, 7
Receipt of a dose up to (and including) 4 days before the birthday will satisfy the school entry immunization requirement.
Two doses of measles-containing vaccine required. One dose of mumps and rubella-containing vaccine required; mumps
vaccine is not required for children 7 years of age and older.
Not required for 7th grade.
Physician-documented varicella (chickenpox) disease history or immunity meets the varicella requirement.
Tdap, DTaP, or DTP given on or after 7th birthday will meet the requirement. Td does not meet the requirement.
2 dose varicella requirement for ages 13-17 years applies to transfer students who were not admitted to a California school
before July 1, 2001.
8th-12th grade students transferring from outside of California must meet the requirement.
EXEMPTIONS
The law allows parents/guardians to choose an exemption from immunization requirements based on their
personal beliefs or medical conditions. For children with medical exemptions, the physician’s written statement should be submitted. Schools should maintain an up-to-date list of pupils with exemptions, so they
can be excluded quickly if an outbreak occurs.
NOT MEETING
REQUIREMENTS
Refer pupils who do not meet these State requirements to their physician or local health department. Give
families a written notice indicating which doses are lacking.
CONDITIONAL
ADMISSIONS
Children who lack one or more required vaccine doses that are not currently due may be admitted
on condition that they receive the remaining doses when due (Title 17, CCR Section 6035).
IMM-231 (4/12)
California Department of Public Health • Immunization Branch • ShotsForSchool.org
14
IMPORTANT MESSAGE FOR PARENTS
HEALTH EXAM AND IMMUNIZATIONS ARE REQUIRED FOR SCHOOL
Success in school starts with a healthy child. Your child is required by California State Law to have a
health check-up and immunizations (shots) before starting Kindergarten or First Grade. The health checkup may be done as early as (6) six months before your child starts Kindergarten and up to (3) three months
after he/she starts First Grade. Immunizations, however, must be up-to-date before your child is admitted
to school.
The health exam should include:
•
•
•
•
•
A complete health history
A “head-to-toe” physical exam
Vision and hearing tests
Urine and blood tests
Immunizations
See your child’s doctor for the health exam. If you do not have a doctor, call the Child Health and Disability
Prevention Program (CHDP) at (650) 573-2877 for help in finding one.
Children who have Medi-Cal can receive the exam free of charge. Children from low income families may
also be eligible for these free exams through CHDP. For example, a family of (4) four can earn up to
$3,725 per month or $44,700 per year and qualify.
When you take your child for the health exam be sure to take your child’s Immunization Record (yellow
card) and “Report of Health Examination for School Entry” form. (included in this packet)
Return the completed health form and updated immunization record to your child’s school as soon as your
child has been seen by the doctor. If you do not want your child to get a health exam or immunizations,
you will need to sign a waiver form at your child’s school.
If you have any questions, please call your child’s school or CHDP at (650) 573-2877.
August 2011
County of San Mateo
IMPF
MENSAJE IMPORTANTE PARA PADRES DE FAMILIA
PARA ENTRAR EN LA ESCUELA SU NIÑO/A NECESITA UN
EXAMEN MEDICO Y VACUNAS
El éxito en la escuela comienza con buena salud, por lo tanto, su niño/a necesita un examen médico y
vacunas antes de empezar el kinder/primer año escolar, requerido por la ley estatal de California. El
examen médico puede hacerse seis meses antes de empezar el kinder o hasta tres meses después de
iniciar su primer grado. Recuerde que su niño/a debe estar al día con las vacunas antes de ser admitido en
la escuela.
El Examen Médico debe incluir:
•
•
•
•
•
Una historia completa de salud
Un examen físico de “pies a cabeza”
Un examen de la vista y de los oídos
Análisis de la sangre y de la orina
Las vacunas que le hagan falta
Visite al doctor de su niño(a) para un examen médico. Si no tiene undoctor, llame al “Programa de Salud
para La Prevención de Incapacidades en Niños y Jóvenes” (CHDP) teléfono (650) 573-2877 para ayudarle
a encontrar un medico
Niños y jóvenes que tienen Medi-Cal pueden recibir exámenes de salud gratis. Niños y jóvenes en familias
de bajos ingresos también pueden ser elegibles para exámenes médicos gratis a través del programa
CHDP. Por ejemplo, una familia de cuatro personas puede ganar hasta $3,725 al mes o $44,700 al año y
califica para nuestro programa.
Cuando vaya al Examen Médico asegúrese de llevar:
• Registro de vacunación (la tarjeta de vacunas amarilla)
• La forma “Reporte del Examen de Salud para el Ingreso a la Escuela” ("Report of Health
Examination for School Entry")
Lleve a la escuela el reporte de su niño(a) tan pronto el doctor se lo entregue. Si no desea que a su niño(a)
se le examine o vacune, Ud.tiene que firmar una forma, "Renuncia Voluntaria para Recibir un Examen de
Salud para Ingresar a La Escuela".
Si tiene preguntas, por favor llame a la escuela o al programa CHDP, teléfono (650) 573-2877.
August 2011
County of San Mateo
IMPF
Millbrae School District
Student Health Inventory
Student’s Name:
School:
Address:
Date of Birth:
Telephone #:
Family Physician and #:
Teacher:
Family Dentist and #:
Grade:
Room #:
Please check which of the following conditions your child has had and give his/her age at the time of the illness and whether he or she is still under
care of a physician for this condition.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
Approximate Age
Allergies
a. Bee stings
b. Foods - specify :
_______
_______________________________
_______
c. other:
Asthma
Diabetes
Heart Condition
Rheumatic fever
Kidney disease
Epilepsy
Convulsions
Polio
Serious accidents or injuries
Tuberculosis, or tuberculosis contact
Frequent or severe headaches
Frequent or severe dizziness
Fainting
Any problem with speech?
Any problem with hearing?
Any problem with vision?
Any problem with teeth?
Emotional problem
Under Care of Physician
20. Is there any other physical condition that the school should be made aware of ?
21. Is physical activity limited? ⁪Yes ⁪ No
22. If yes, is there a physician’s statement on file with the school? According to the school code, there must be a physician’s written statement.
glasses
leg braces
⁪
⁪
contact lenses
crutches
⁪
⁪
hearing aid
corrective shoes
⁪
⁪
dental braces
other
⁪
⁪
23. Does your child have any condition which could be a school emergency?
_______
24. Is your child presently taking any medicine prescribed by a physician? (Explain)
_______
Parent/Guardian Signature
Date
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registrationinfo.1.10.13
17
Distrito Escolar de Millbrae
Informacion Sobre la Salud del Estudiante
Nombre del alumno(a):
Escuela:
Direccion:
Feche de Nacimiento:
Telefono:
Nombre del Medico:
Maestro de Clase:
Nombre del Dentista:
Grado:
Aula No:
Por favor indicar cuales de las siguientes afecciones ha padecido o padece su hijo(a) y tambien indicar si se encuentra actualmente bajo
tratamiento medico por ese padecimiento.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
Alergias
a. picada de abeja
b. comidas (especifica) :
_____________________________
Edad que comenzó
Bajo cuidado médico
c. otra:
Asma
Diabetes
Afecciones cardiacas
Fiebre reumatica
Enfermedades de los rinones
Epilepsia
Convulsiones
Poliomelitis
Accidentes graves o heridas graves
Tuberculosis o contactos con TB
Dolores de cabezas fuertes y frecuentes
Mareos fuertes y frecuentes
Desmayos
Problemas con el hablar
Problemas con los oídos
Problemas de la vista
Problemas de los dientes
Problemas de caracter emocional
20. Hay algun padecimiento en la salud de su niño(a) que considera importante y de informar a la escuela fuera de esta lista? Por favor
explique al dorso de la hoja.
21. Tiene su hijo(a) alguna dificultad en cuanto a alguna actividad física? ⁪ SI ⁪ NO
22. Si la respuesta es SI ya le informó sobre ésto a la escuela? Si existe alguna condición que cause que su hijo(a) tenga una actividad
física limitada, la escuela necesita una certificación médica y la cual debe de actualizarse cada seis meses. Si su hijo(a) utiliza cualquier
aparato o instrumentos de los cuales la escuela debe de estar enterada? De ser así por favor marque.
anteojos
⁪
frenos para los dientes
⁪
⁪
lentes de contacto ⁪
zapatos correctivos
aparatos en las piernas
cualquier otro
⁪
⁪
aparato para el oído
muletas
⁪
⁪
23. Tiene su hijo(a) algun padecimiento de salud que podría presentarse una emergencis en la escuela?
24. Si la requesta es SI por favor explicar al reverso de la hoja
Está su hijo(a) tomando alguna medicina bajo receta médica? Si la respuesta es SI, por favor explique___________
Firma de los padres/guardian
Fecha
E11
Registrationinfo.1.10.13
18
REPORT OF HEALTH EXAMINATION FOR SCHOOL ENTRY
Department of Health Care Services
Child Health and Disability Prevention (CHDP) Program
DATE (mm/dd/yy)
OTHER
PM 171 A (09/07) (Bilingual)
Signature of health examiner
Name, address, and telephone number of health examiner
Signature of parent or guardian
Date
Date
Please check this box if you do not want the health examiner to fill out Part III.
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.
CHDP website: www.dhcs.ca.gov/services/chdp
Conditions found in the examination or after further evaluation that are of importance to schooling or
physical activity are: (please explain)
Examination shows no condition of concern to school program activities.
Fill out if patient or guardian has signed the release of health information.
DATE EACH DOSE WAS GIVEN
Second
Third
Fourth
Fifth
RELEASE OF HEALTH INFORMATION BY PARENT OR GUARDIAN
First
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.
and
OTHER (e.g., TB Test, if indicated)
______/______/______
VARICELLA (Chickenpox)
HEPATITIS B
HIB MENINGITIS (Haemophilus Influenzae B)
(Required for child care/preschool only)
MMR (measles, mumps, and rubella)
DtaP/DTP/DT/Td (diphtheria, tetanus, and [acellular]
pertussis) OR (tetanus and diphtheria only)
POLIO (OPV or IPV)
VACCINE
______/______/______
______/______/______
______/______/______
______/______/______
______/______/______
______/______/______
______/______/______
______/______/______
______/______/______
______/______/______
______/______/______
ADDITIONAL INFORMATION FROM HEALTH EXAMINER (optional)
RESULTS AND RECOMMENDATIONS
PART III
Health History
Physical Examination
Dental Assessment
Nutritional Assessment
Developmental Assessment
Vision Screening
Audiometric (hearing) Screening
TB Risk Assessment and Test, if indicated
Blood Test (for anemia)
Urine Test
Blood Lead Test
Other
REQUIRED TESTS/EVALUATIONS
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).
SCHOOL
IMMUNIZATION RECORD
ZIP code
BIRTH DATE—Month/Day/Year
NOTE: All tests and evaluations except the blood lead test
must be done after the child is 4 years and 3 months of age.
TO BE FILLED OUT BY HEALTH EXAMINER
City
Middle
HEALTH EXAMINATION
PART II
ADDRESS—Number, Street
First
TO BE FILLED OUT BY A PARENT OR GUARDIAN
CHILD’S NAME—Last
PART I
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.
State of California—Health and Human Services Agency
INFORME DEL EXAMEN DE SALUD PARA EL INGRESO A LA ESCUELA
Department of Health Services
Child Health and Disability Prevention (CHDP) Program
Ciudad
MMR (sarampión, paperas, rubéola)
HIB MENINGITIS (Hemófilo, Tipo B)
(Requerida para centros de cuidado para niños y centros
preescolares solamente)
______/______/______
OTRA (e.g. prueba TB, de ser indicado)
OTRA
______/______/______
VARICELLA (Viruelas locas)
______/______/______
______/______/______
______/______/______
______/______/______
______/______/______
______/______/______
HEPATITIS B
DTaP/DTP/DT/Td (difteria, tétano y [acellular] pertusis
[tos ferina]) O (tétano y difteria solamente)
______/______/______
______/______/______
POLIO (OPV o IPV)
______/______/______
______/______/______
Escuela
FECHA DE NACIMIENTO—Mes/Día/Año
Firma del examinador de salud
Firma del padre/madre o guardián
Fecha
Fecha
PM 171 A (3/03) (Bilingual)
Si su niño o niña no puede obtener el examen de salud llame al Programa de Salud para la Prevención de Incapacidades de Niños y Jovenes (Child Health and Disability Prevention Program)
en su departamento de salud local. Si Ud. no desea que su niño(a) tenga un examen de salud, puede firmar la orden (PM 171 B), formulario que se consigue en la escuela de su niño(a).
CHDP website: www.dhcs.ca.gov/services/chdp
*de ser indicado
Las condiciones encontradas en el examen o después de una evaluación posterior que son de
importancia para la actividad escolar o física son: (por favor explique)
El examen reveló que no hay condiciones que conciernen las actividades de los programas
escolares.
PARTE III
INFORMACIÓN ADICIONAL DEL EXAMINADOR DE SALUD (optional)
PERMISO PARA DIVULGAR (DISTRIBUIR) EL INFORME DE SALUD
y
RESULTADOS Y RECOMENDACIONES
Yo le doy permiso al examinador de salud para que comparta con la escuela la información adicional
Llene esta parte si el padre/la madre o el guardián ha firmado el consentimiento para divulgar
de este examen como es explicado en la Parte III.
(distribuir) la información de salud de su niño/niña.
Por favor marque esta caja si Ud. no desea que el examinador llene la Parte III.
Historia de Salud
Examen Físico
Evaluación de Dientes
Evaluación de Nutrición
Evaluación del Desarrollo
Pruebas Visuales
Pruebas con Audiómetro (auditivas)
Evaluacion de Riesgo y prueba Tuberculosis*
Análisis de Sangre (para anemia)
Análisis de Orina
Análisis de Sangre para el plomo
Otra
PRUEBAS Y EVALUACIONES REQUERIDAS FECHA(mm/dd/aa)
Zona Postal
Segundo Nombre
REGISTRO DE INMUNIZACIONES
Aviso al Examinador: Por favor dé a la familia, una vez completado, o a la fecha, el Registro de Inmunización de California en
papel amarillo.
Aviso a la Escuela: Por favor apunte las fechas de inmunización sobre el Registro de Inmunización de la escuela de California
en papel azul.
FECHA EN QUE CADA DOSIS FUE DADA
VACUNA
Primero
Segundo
Tercero
Quarto
Quinto
PARA SER LLENADO POR EL EXAMINADOR DE SALUD
EXAMEN DE SALUD
AVISO: Todas las pruebas y evaluaciones excepto el análisis
de sangre para el plomo deben ser hechas después de la edad
de 4 años y 3 meses.
PARTE II
DOMICILIO—Número y Calle
Primer Nombre
PARA SER LLENADO POR EL PADRE/LA MADRE O EL GUARDIÁN
NOMBRE DEL NIÑO/NIÑA—Apellido
PARTE I
Para proteger la salud de los niños, la ley de California exige que antes de ingresar a la escuela todos los niños tengan un examen médico de salud. Por favor, pidale al examinador de
salud que llene este informe y entregelo a la escuela—este informe sera archivado por la escuela en forma confidencial.
State of California—Health and Human Services Agency
CLINICAS DE VACUNAS Y EXAMENES DE SALUD
*
*
*
Condado
Sur
Generalmente no hay cobro por servicios de exámenes de salud y vacunas.
Niños y jóvenes menores de 18 años deben ser acompañados por uno de sus padres.
Por favor, no olvide presentar su tarjeta de vacunas.
Fair Oaks Children’s Clinic
630 Laurel Street, Redwood City, 94063
261-3710 Cita previa es necesaria
Mobile Health Van (Solamente Vacunas)
Redwood City Habrá un cobro mínimo
573-2786 Cita previa no es necesaria
Ravenswood Family Health Center
1798 – A Bay Road, East Palo Alto, 94303
Ravenswood Family Health Center (Solamente Vacunas)
330-7400 Cita previa no es necesaria - Edades 3 - 18 años
Belle Haven Clinic (Solamente Vacunas)
100 Terminal Avenue, Menlo Park, 94025
321-0980 Cita previa no es necesaria – Edades 3 - 18 años
Belle Haven Clinic
Lunes a Viernes
8:30 am -11:00 am
1:00 pm - 3:45 pm
Llamar para días, horas y sitios
Lunes, Miércoles, Jueves 8:00 am - 6:00 pm
Martes 12:30 pm - 6:00 pm
Viernes 8:00 am – 5:00 pm
Lunes y Miércoles
1:00 pm – 4:00 pm
Martes
1:00 pm – 4:00 pm
Lunes, Miercoles, Jueves, Viernes
8:00 am – 5:00 pm
Martes 12:30 pm – 5:00 pm
Oficina Cierra Lunes – Viernes 11:30 am–12:30 pm
Condado
Central
Condado
Norte
Costa
Sequoia Teen Wellness Center
200 James Avenue, Redwood City, 94062
366-2927 Cita previa es necesaria – Edades 12-18 años
Lunes a Viernes
8:30 am -11:00 am
1:00 pm – 3:30 pm
Willow Clinic
795 Willow Road, Bldg 334, Menlo Park, 94025
Lunes, Martes, Miércoles, Viernes
8:00 am - 12:00 pm, 1:00 pm - 5:00 pm
Jueves
8:00 am – 12:00 pm, 1:00 pm – 9:00 pm
2do Jueves de cada mes
4:00 pm - 5:30 pm
Martin Luther King, Jr. Community Center
(Solamente Vacunas)
725 Monte Diablo Avenue, San Mateo, 94401
573-2877 Cita previa no es necesaria- Edades 2-18 años
San Mateo Habrá un cobro mínimo
San Mateo Medical Center Clínica de Pediatría
th
222 39 Avenue, San Mateo, 94403
573-3602 Llame para una cita
Seton RotaCare Clinic (Solamente Vacunas)
Seton Medical Center
1900 Sullivan Avenue (Planta Baja), Daly City, 94015
Daly City Youth Health Center
2780 Junipero Serra Blvd., Daly City, 94015
985-7000 Cita previa es necesaria - Edades 14 - 21 años
South San Francisco y San Bruno
Habrá un cobro mínimo
Daly City Clinic
380 90th Street, Daly City, 94015
South San Francisco Health Center
306 Spruce Avenue South San Francisco, 94080
San Mateo Medical Center Coastside Clínica de Pediatría
225 South Cabrillo Hwy, Half Moon Bay, 94019
573-3941 Llame para una cita
Lunes a Jueves 8:00 am – 7:00 pm
Sábado 8:30 am - 2:00 pm
4to Lunes de cada mes
5:00 pm - 7:00 pm
Lunes, Martes, Miércoles, Viernes
9:30 am - 11:30 am, 1:00 pm – 5:00 pm
Jueves 1:00 pm – 5:00 pm
Lunes 8:30 am – 9:00 pm
Martes, Miercoles, Jueves, Viernes
8:30 am - 5:00 pm
Lunes a Jueves 8:00 am – 8:30 pm
Lunes, Martes, Miercoles, Viernes
8:00 am – 4:00 pm
Jueves 8:00 am – 6:00 pm
Sabado 8:00 am – 3:00 pm
CONDADO DE SAN MATEO PROGRAMA DE INMUNIZACIONES - (650) 573-2877
Revisado Agosto 2013
HEALTH EXAM AND IMMUNIZATION CLINICS
*
*
*
South
County
Generally, health exams and immunizations are provided at no cost.
Children and youth under 18 years of age must be accompanied by a parent or caregiver.
Bring all available immunization records.
Fair Oaks Children’s Clinic
Monday through Friday
8:30 am – 11:00 am
630 Laurel Street, Redwood City, 94063
1:00 pm – 3:45 pm
Phone: 261-3710 By appointment only
Call for days, times and locations
Mobile Health Van (Immunizations Only)
Redwood City Minimum Fee Charged
Phone: 573-2786 No appointment needed
Monday, Wednesday, Thursday 8:00 am -6:00 pm
Tuesday 12:30 pm - 6:00 pm
Friday 8:00 am - 5:00 pm
Monday and Wednesday
Drop – In Immunization Clinic
1:00 pm – 4:00 pm
Phone: 330-7400 No appointment needed – Ages: 3-18 yrs
Belle Haven Clinic Drop-In Immunization Clinic
Tuesday
1:00 pm – 4:00 pm
100 Terminal Way, Menlo Park, 94025
Phone: 321-0980 No appointment needed - Ages: 3 – 18 yrs
Belle Haven Clinic
Monday, Wednesday, Thursday, Friday
8:00 am – 5:00 pm.
Tuesday 12:30 pm – 5:00 pm
Office closes Monday – Friday 11:30 am – 12:30 pm
Mid
County
North
County
Sequoia Teen Wellness Center
200 James Avenue, Redwood City, 94062
Phone: 366-2927 By appointment only- Ages 12-18 yrs
Willow Clinic
795 Willow Road, Bldg 334, Menlo Park, 94025
Martin Luther King, Jr. Community Center
(Immunizations Only)
725 Monte Diablo Avenue, San Mateo, 94401
Phone: 573-2877 No appointment needed - Ages 2-18 yrs
San Mateo Minimum Fee Charged
San Mateo Medical Center Pediatric Clinic
222 39th Avenue, San Mateo, 94403
Phone: 573-3602
Call for an appointment
Seton RotaCare Clinic (Immunizations Only)
Seton Medical Center
1900 Sullivan Avenue (Lower Level), Daly City, 94015
Daly City Youth Health Center
2780 Junipero Serra Blvd., Daly City, 94015
Phone: 985-7000 - By appointment only
Monday through Friday
8:30 am – 11:00 am
1:00 pm – 3:30 pm
Monday, Tuesday, Wednesday, Friday
8:00 am – 12:00 noon, 1:00 pm – 5:00 pm
Thursday 8:00 am –12:00 pm,1:00 pm–9:00 pm
nd
2 Thursday of every month
4:00 pm – 5:30 pm
Monday through Thursday
8:00 am – 7:00 pm
Friday 8:00 am – 4:30 pm
Saturday 8:30 am – 2:00 pm
th
4 Monday of every month
5:00 pm - 7:00 pm
9:30 am – 11:30 am, 1:00 pm – 5:00 pm
Thursday 1:00 pm – 5:00 pm
Ages: High School age to 21 yrs
South San Francisco & San Bruno Minimum Fee Charged
Daly City Clinic
380 90th Street, Daly City, 94015
South San Francisco Health Center
306 Spruce Avenue, South San Francisco, 94080
San Mateo Medical Center Coastside Pediatric Clinic
Coastside 225 South Cabrillo Hwy, Half Moon Bay, 94019
Phone: 573-3941 Call for an appointment
Revised August 2013
Monday 8:30 am – 9:00 pm
Tuesday, Wednesday, Thursday, Friday
8:30 am – 5:00 pm
Monday through Thursday 8:00 am – 8:30 pm
Friday 8:00 am – 5:00 pm
8:00 am – 4:00 pm
Thursday 8:00 am – 6:00 pm
Saturday 8:00 am – 3:00 pm
SAN MATEO COUNTY IMMUNIZATION PROGRAM (650) 573-2877
Millbrae School District  555 Richmond Drive  Millbrae, CA 94030
650-697-5693  650-697-6865 (fax)  millbraeschooldistrict.org
Dear Parents and Guardians,
Keep Millbrae Schools Great
Support BOTH the MEF and your PTA!
Welcome to the Millbrae School District! We are so happy to receive your new enrollment to our fine schools
here in Millbrae and count it an honor to be a part of your student’s education. Our schools are GREAT because
of the wonderful community, parents and staff that make each of our schools unique through hard work and
collaboration on behalf of children. All of us play an important role in making your student’s years here in the
Millbrae School District a positive, rigorous learning experience.
In a time of slow fiscal recovery in our State and the continued lack of funding to Public Education, both the PTA
and the MEF play critical roles at our schools. It is only through the support of parents and our Millbrae
Community that we can continue to fund specific school needs, as well as additional staff for essential districtwide programs at all of our schools.
Parent Teacher Associations (PTAs)
Help fund school specific
materials and programs.
Materials and Programs include:








Classroom supplies
Technology
Field trips
Newsletters
Assemblies
Art programs and supplies
Teacher appreciation
School-based events
Millbrae Education Foundation (MEF)
Helps fund district-wide programs
and teaching personnel.
During the 2013-2014 school year,
the MEF funded:
 A full-time Music Teacher for all elementary
schools to participate and experience music
education.
 Two (2) Technology Specialists in moving our
district closer to 21st century learning skills and
preparing for the Common Core and new
assessments.
 Additional staff development in technology for
staff.
 A district-wide parent communication system.
For more information on how you can support your PTA and the MEF visit:
• Millbrae Education Foundation: http://www.millbraeeducationfoundation.org
• Green Hills Elementary PTA: http://www.millbraeschooldistrict.org/greenhills/PTA.html
• Lomita Park Elementary PTA: http://www.millbraeschooldistrict.org/lomitapark/index.htm
• Meadows Elementary PTA: http://meadows.millbraeschooldistrict.org/pta.htm
• Spring Valley Elementary PTA: http://sites.google.com/site/springvalleyelementary/pta-corner
• Taylor Middle School PTA: http://taylormiddleschoolpta.org/
Thank you, in advance, for your support and participation in our PTA and MEF. Together we will continue to
make a great difference in the lives of students!
Sincerely,
Linda Chin Luna,
Superintendent
BOARD OF TRUSTEES
FRANK BARBARO  DENIS FAMA  LYNNE FERRARIO  JAY D. PRICE  D. DON REVELO
An Equal Opportunity Employer
Our kids. Our future. Our choice.
2014-15 School Year Registration
MILLBRAE EDUCATION FOUNDATION
Supporting Millbrae’s Public Schools Green Hills * Lomita Park * Meadows * Spring Valley * Taylor Middle School
MillbraeEducationFoundation.org
Our kids. Our future. Our choice.
2014-15 School Year Registration
MillbraeEducationFoundation.org

January 15, 2014 - Millbrae School District

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