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Kidney Disorder
Medical Procedures required at
schoolMedication Prescribed (explain)
Medication needed at school
Menstrual Cramps (severe)
Migraine Headaches medication
requiredMumps
Muscular Dystrophy
Nose Bleeds (Frequent)
Osgood-Schlatter Disease
Physical Activity Limitation
Rheumatic Fever history
Rubella: 3-day Measles
Is the student Hispanic or Latino? Rubeolla: 10-day Measles
No, not Hispanic or Latino Scarlet Fever Name Grade School of AttendanceYes, Hispanic or Latino Scoliosis
Sickle Cell Anemia (explain below)
Tuberculosis
Ulcer
Vision Impairment (glasses/contacts)
Vision Impairment (visual handicap)
Comments:
Race - What is the race of this student?
(select 1 or more)
American Indian or Alaska Native Medical Comments:
Chinese
Japanese
Korean
Vietnamese My child has not participated in any Special Education Programs
Asian Indian My child has been tested but is not in any Special Education Program
Laotian My child has participated or is currently in a Special Education Program
Cambodian and has an IEP
Filipino My child has participated in a Special Education Program but has exited the Please complete the following questions:
Hmong program per
his/her IEP
Which language did your child learn when they first began to talk?
Other Asian FOR OFFICE USE ONLY
Hawaiian Special education program designation Which language does your child most frequently speak at home?
Guamanian
Samoan Which language do you most frequently use when speaking with
Tahitian Registration Comments your child?
Other Pacific Islander Which language is most often spoken by the adults in the home?
B
Black or African American ________________________________________________________White
Revised 2/27/2012 LT
EM
ER
GE
NC
Y C
ON
TA
CT
S
Endocrine Disorder
Hearing Loss
What date did your student first enroll in a United
States school?
Month: ________________
Year: ____________
What date did your student first enroll in a California
school?
Month: ________________
Year: ____________
The above part of the question is about ethnicity,
not race. No matter what you selected please
continue marking one or more boxes to indicate
what you consider your race to be.
ET
HN
IC O
RIG
INS
HO
ME
LA
NG
UA
GE
SU
RV
EY
SP
EC
IAL
ED
UC
AT
ION
Hearing Aid Used
Chicken Pox
Heart Disease/Defect
ME
DIC
AL
IN
FO
RM
AT
ION
NAME OF OTHER STUDENTS IN THE HOME
Name and phone #
(other than parent/guardian)
Relationship to Student
The California Education Code requires schools to determine the language(s) spoken at home by
each student. This information is essential for the school to provide adequate instructional program and
services. As parents or guardians, your cooperation is requested in complying with this legal
requirement. (CA Dept. of Ed. HLS 10/05). Please note that if you respond with a language other than
English to any of these 4 questions, your child may be identified as an English Learner and will receive
appropriate services to support English Language Development.
Cerebral Palsy
Eating Disorder
Cancer/Leukemia
Arthritis
Asthma
Attention Deficit/Hyperactivity
(ADHD)Birth Defect/Chromosome Disorder
Growth Disorder
STUDENT EDUCATIONAL HISTORY
No Known Health Problems
Allergy: Food (explain )
Blood/Blood Products-not given
Allergy:Medication (explain )
Anemia
Allergy:Pollen, dust, hay fever, insects
What date did your student first enter the United
States?
Month: ________________
Year: ____________
Cystic Fibrosis
Blood Disorder/Hemophilia
Epilepsy/Seizure Medication
Required
Diabetic/ Insulin Dependent
___yes___no