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School OfficeUseOnly:
Date Received by________
School of Residence
TRANSITIONALKINDERGARTEN
2021-2022SCHOOLYEAR
ENROLLMENTPACKET
SANBRUNOPARKSCHOOLDISTRICT
(TKschoollocationstobedetermined)
ForchildrenbornbetweenSeptember2,2016andDecember2,2016
Please return completed packets
to your child's resident school for
processing.
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500 Acacia Avenue • San Bruno, California 94066-4222 • Phone:
650-624-3100 FAX: 650-266-9626
Colleen Hennessey, PrincipalSAN BRUNO PARK SCHOOL DISTRICT
TRANSITIONAL KINDERGARTEN
Anita Allardice Director of Special Education and Student
Services
(650) 624-3114
WELCOMETOTRANSITIONAL KINDERGARTEN!
2021-2022(DOB between 9/2/16 & 12/2/16)
Pleasecompleteandreturnthefollowingdocumentsassoonaspossible.Inordertocompletetheregistrationandputyourchild’snameontheroster,theitemswith(**)mustbecompleteandreturnedtothisoffice.
**StudentRegistrationForm**ResidencyAffidavitforSchoolEnrollment**Health
History Form
Otherdocumentationneededforregistration:
**OriginalBirthCertificate/BaptismalCertificate
**Currentimmunizations**Proofofresidency(twoofthefollowing):
_____currentPG&Ebillordepositreceiptforservice_____rentalagreementswithacanceledcheckorreceipt_____currentlandlinetelephonebill(notcellphone)showingcorrectaddress_____currentutilityorwaterbillshowingcorrectaddress_____homeowner’sinsurancestatementshowingcorrectaddress_____escrowpapersshowingpurchaseofhome_____propertytaxpaymentreceipts
CurrentTBTestResults(withinthelast12months)priortoentryinto
1stgradeorwhen
enteringschoolfromoutsidetheContinentalU.S.(B.P.5141.26)
ForKindergarten and
TK,pleasecompleteandreturntheformsbelowaftermedicalanddentalappointments.Pleasemakeyourchild’sphysicalappointmentafterMarch2,2021.
ReportofHealthExamination(tobecompletedbyyourchild’sphysician)
UpdatedImmunizations(ifneeded)
DentalExamForm
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SAN BRUNO PARK SCHOOL DISTRICT Student Registration Form
2021-2022
STUDENT INFORMATION Month Day Year
__________________________________________
_______________________________ ____ _________/_______/_______
_______________Last Name First Name MI Birthdate Gender
( ) __________________
________________________________________________
________________________________ _______________ Home Phone Address
City ZIP
Current Grade ______________ Last school attended:
_____________________________________________________________
( ) ( )
Previous School Address City State Zip Phone Fax
Special Programs: ☐Yes ☐No
☐ English Learner ☐Expulsion
☐ 504 Plan ☐ GATE ☐Other _____________
Special Education: ☐ Yes ☐No
☐Speech ☐RSP ☐SDC ☐OT
☐ Other Services __________________
Has this child ever repeated a grade? ☐ No ☐ Yes If YES, which
grade? __________
Birth
Place?_____________________________________________________________________________________________________________________
Hospital Name City State Country
First year your child attended school in US ________________
Where? ___________________________________________________ City
State
First year your child attended school in CA ________________
Where? ___________________________________________________ City
PARENT/GUARDIAN PARENT/GUARDIAN Relationship to student
Relationship to student Name Name Home Address Home Address Home
Phone Home Phone Work Phone Work Phone Cellular Phone Cellular
Phone Employed by Employed by Occupation Occupation E-mail address
E-mail address
☐High School Grad ☐Not High School Grad☐Some College (or. AA)
☐College Grad☐Masters or Higher ☐Decline to Answer/Unknown☐Active
Duty Armed Forces or National Guard
☐High School Grad ☐Not High School Grad☐Some College (or AA)
☐College Grad☐Masters or Higher ☐Decline to Answer/Unknown☐Active
Duty Armed Forces or National Guard
SCHOOL USE ONLY Date Records Requested ___________________ Date
Records Received ________________
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SAN BRUNO PARK SCHOOL DISTRICT Student Registration Form
2021-2022
In case the school is unable to contact either parent in the
event of any emergency or major disaster, the school may call or my
child may be released to any of the people listed below:
DAYTIME PHONE NUMBERS Name Relationship Home/Work Phone Cell
Phone
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( )
OTHER CHILDREN IN HOUSEHOLD Last Name First Name Birthdate Sex
School
What is your preferred language of communication?
_____________________________________________________________________
Please answer by marking one or more boxes to indicate what you
consider your race to be: □ African American/Black□ American
Indian/Alaska Native□ Asian Indian□ Cambodian□ Chinese□
Filipino
□ Guamanian□ Hawaiian□ Hmong□ Japanese□ Korean□ Laotian
□ Other Asian□ Other Pacific Islander□ Samoan□ Tahitian□
Vietnamese□ White
Ethnicity: Is student Hispanic or Latino: No, not Hispanic or
Latino Yes, Hispanic or Latino
******* 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-prescription drugs including aspirin or aspirin substitutes)
will be given at school unless the above conditions are met.
☐ I CONSENT FOR EMERGENCY TREATMENT if it is deemed necessary by
the school authorities and after all effortsto reach the parent or
designated adult have failed. Your child will be taken by ambulance
at parent’s expense to thenearest emergency facility.
I WILL NOTIFY THE SCHOOL EACH TIME THERE IS A CHANGE IN ANY OF
THIS INFORMATION.
___________________ Date
________________________________________________________
Parent/Guardian Signature
SCHOOL USE ONLY Date Records Requested ___________________ Date
Records Received ________________
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500 Acacia Avenue, San Bruno, CA 94066-4222 Tele:
650.624.3100
SanBrunoParkSchoolDistrictRESIDENCYAFFIDAVITFORSCHOOLENROLLMENT
2021-2022
Onlystudents residing within the area served by the school
district, who are able to furnish a permanent address within the
district’s
boundaries,willbepermittedtoattendtheschoolsofSanBrunoParkSchoolDistrict.
ResidenceforschoolattendancepurposesisdeAinedastheresidenceoftheparentorlegalguardian.
TO BE COMPLETED BY PARENT/GUARDIAN:
Student:(Last,FirstName)
Parents/Guardian(Last,FirstName) (Last,FirstName)
StreetAddress: City:
HomePhone: CellPhone: WorkPhone:
In a single family residenceWith more than one family in a house
or apartment due to economic hardshipWith more than one family in a
house or apartment NOT due to economic hardshipIn a shelter or
transitional housing programIn a motel/hotel, car or campsite or
similar location
Other____________________________________________________________________________________
Where is your child/family currently living? (Check one box
only) This information will be used to determine if this student
may be eligible to receive services or supports under the
McKinney-Vento Act 42 U.S.C. 11435. All information will be kept
confidential and will not be shared with anyone other than
designated SBPSD staff.
SignatureofParent/LegalGuardian Date
Pleaseprovideanytwoofthefollowing,showingtheparents/guardian’snameandcorrectaddress:
_____ CurrentPG&E, utility, or waterbill or deposit for
service_____ Rental agreements with a canceled check or
receipt_____ Currentlandline telephonebill(not a cell phone)
showing correct address _____ Homeowners insurance statement
showing correct address _____ Escrowpapers showing purchase of
home_____ Propertytaxpayments
DistrictPolicyAR5111.1Ifanydistrictemployeereasonablybelievesthattheparent/guardianofastudenthasprovided
falseorunreliableevidenceofresidency,TheSuperintendentordesigneeshallmakereasonableeffortstodeterminethatthestudentmeetslegalresidencyrequirements.
IverifythatIamthenaturalparent,thecustodialparent,thelegalguardianorthecaregivingadultofthestudentnamedabove.Theaddresslistedaboveismyonlyresidence.Iagreetonotifythe
SBPSDifthereisanychangeinthestatusoftheresidencyofthestudentlistedabove.I
understandthathomevisitationand/orresidencyveriAicationispartofaperiodicprocesswhenresidencyis
establishedbyresidencyafAidavit.Shoulditbedeterminedthatresidencerequirementsarenot
beingsatisAied,thestudent’senrollmentshallbeterminatedimmediately,withpropernotiAicationtotheparent/legalguardian.
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SAN BRUNO PARK SCHOOL DISTRICT/DISTRITO ESCOLAR DE SAN
BRUNOHEALTH HISTORY/HISTORIA de SALUD
Student’s Name:
________________________________________________________________________________________
Birth Date: _____________________________________________
(Nombre de Estudiante) (Fecha de Nacimiento)
Student I.D. #:
____________________________________________________School:
_____________________________________________ Grade:
___________________________________ (Número de I.D. del estudiante)
(Escuela) (Grado)
Does your child have any of the following? (please check all
that apply) ¿Tiene su Niño(a) alguno de lo siguiente?(marque lo que
tiene)
Yes/Si No Specify/Específique
ADHD
Allergies/Alergias
Asthma/Asma
Chemically Sensitive/Sensitivo a químicos
Ear Infections/Infecciones del oído
Epilepsy or Seizures/Epilepsia o ataques
Hearing Problems/Problemas de oir
Heart Condition/Condición del Corazon
Other Medical Problems/ Otros problemas médicos
Orthopedic ‘Condition/Condición ortopédica
Speech Problem/Defecto del habla
Takes Daily medication/ ¿Toma medicamento diariamente?
Takes Emergency Medication/¿Toma medicamento de emergenica?
Vision Problems/Problemas de la vista
Any Serious Health Problems/¿algún otro problema serio de
salud?
Bee Sting Allergy/¿Alergia de picadura de abeja? Type of
reaction/¿Tipo de reacción?:
Needs emergency medication? ¿Necesita medicamento de
emergencia?
Birth History/Historia del Nacimiento Pre-term/Prematuro Length
of stay in hospital/estancia en el hospital:
Diabetes /Diabetes Takes Insulin?/ ¿Toma insulina? Yes/Si ____
No ____ (Mark one/marque uno)
MEDICAL INSURANCE INFORMATION / Información de Seguro Médico
Does your child have Medical Insurance? _____Yes/Sí¿Tiene Seguro
Médico su hijo/a? _____No
If yes, provide the name of the insurance company/Si es así,
proveer el nombre del seguro médico:
Name/Nombre:______________________________________________________________
Policy or Group Number/Número de Póliza o Grupo:
Does your child have Medi-Cal? _____Yes/Sí¿Tiene Medi-Cal su
hijo/a? _____No
If yes, provide the BIC Number: Si es así, proveer el número de
tarjeta:
Please bring the insurance/Medi-Cal card with you at the time of
enrollment / Favor de traer la tarjeta médica o de Medi-Cal a la
hora de inscripción
SIGNATURE OF PARENT OR GUARDIAN / Firma de los padres o
tutor:____________________________________________
Date/Fecha:_______________________________
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500 Acacia Avenue, San Bruno, CA 94066-4222
Tele: 650.624.3100
IMPORTANT MESSAGE FOR PARENTS: HEALTH EXAM AND IMMUNIZATIONS ARE
REQUIRED FOR SCHOOL
Dear Parent/Guardian,
Success in school starts with a healthy child. Your child is
required by California State Law to have a health checkup and
immunizations (shots) before starting kindergarten or first grade.
The health checkup may be done as early as six months before your
child starts kindergarten and up to three months after starting
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 assistance.
Children who have Medi-Cal can receive the health exam free of
charge. Children from low income families may also be eligible for
the free exam through CHDP. For example, a family of four can earn
up to $5,564 per month or $66,766 per year and qualify.
When you take your child for the health exam, be sure to take
your child’s Immunization record and the Report of Health
Examination for School Entry form. 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, 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.
Sincerely,
Anita AllardiceDirector Special Education and Student
Services
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PARENTS ’ GUIDE TO IMMUNIZ ATIONS
REQUIRED FOR SCHOOL ENTRY
Starting July 1, 2019
Students Admitted at Transitional Kindergarten and Kindergarten
Need:
• Diphtheria, Tetanus, and Pertussis ( DTaP, DTP ) — 5 doses(4
doses OK if one was given on or after 4th birthday.
• Polio (OPV or IPV) — 4 doses(3 doses OK if one was given on or
after 4th birthday)
• Hepatitis B — 3 doses
• Measles, Mumps, and Rubella (MMR) — 2 doses(Both given on or
after 1st birthday)
• Varicella (Chickenpox) — 2 doses
Records:
California schools are required to check immunization records
for all new student admissions at TK/Kindergarten through 12th
grade and all students advancing to 7th grade before entry. Parents
must show their child’s Immunization Record as proof of
immunization.
Revised 1-2020 SMC California Department of Public Health •
Immunization Branch • ShotsForSchool.org
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500 Acacia Avenue, San Bruno, CA 94066-4222
Tele: 650.624.3100
Dear Parent or Guardian:
To make sure your child is ready for school, California law,
Education Code Section 49452.8, now requires that your child have
an oral health assessment (dental check-up) by May 31 in either
kindergarten or first grade, whichever is their 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 Oral Health Assessment/Waiver Request form to
the dental office, as it will be needed for your child’s check-up.
If you cannot take your child for this required assessment, please
indicate the reason for this in Section 3 of the form. You can get
more copies of the necessary form at your child’s school or online
from the California Department of Education’s Web site at
http://www.cde.ca.gov/ls/he/hn/. 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 or Web site can help
you to find adentist who takes Denti-Cal: 1-800-322-6384;
http://www.denti-cal.ca.gov.For help enrolling your child in
Medi-Cal/Denti-Cal, contact your localsocial service agency.
2. Healthy Families’ toll-free number or Web site can help you
to find adentist who takes Healthy Families insurance or to find
out if your childcan enroll in the program: 1-800-880-5305 or
http://www.benefitscal.com/.
3. For additional resources that may be helpful, contact your
local publichealth department at 650-573-2346.
http://www.cde.ca.gov/ls/he/hn/http://www.denti-cal.ca.gov/http://www.benefitscal.com/
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Remember, your child is not healthy and ready for school if they
have 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 thehealthiest 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 andcandy contain a lot of sugar, which causes cavities and
replacesimportant nutrients in your child’s diet. Sweet drinks and
candy alsocontribute to weight problems, which may lead to other
diseases, suchas diabetes. The less candy and sweet drinks, the
better!
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.
Many things influence a child’s progress and success in school,
including health. Children must be healthy to learn, and children
with cavities are not healthy. Cavities are preventable, but they
affect more children than any other chronic disease.
If you have questions about the new oral health assessment
requirement, please contact your principal.
Sincerely,
Anita Allardice Director Special Education and Student
Services
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Teacher:__________________________Grade_______ California
Department of EducationMarch 2008Page 1 of 2
Oral Health Assessment Form Grades K-1 OnlyCalifornia law
(Education Code Section 49452.8) states your child must have a
dental check-up by May 31 of the first year in public school.
ACalifornia 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:
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 29 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.
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500 Acacia Avenue, San Bruno, CA 94066-4222
Tele: 650.624.3100
BOARD OF TRUSTEES:
Jennifer M. Blanco • Teri Chavez • Andrew T. Mason • Henry
Sanchez, M.D. • Andriana Shea
Jose Espinoza, Superintendent
Dear Parent,
The San Bruno Park Elementary School District is required to
comply with section 205 of the Healthy, Hunger-Free Kids Act of
2010 (Public Law 111-296) of a gradual increase to paid lunch
pricing. Effective August 27, 2020 “paid” breakfast prices will
increase by $0.25 and lunch will increase by $0.35 for K-5 and $.50
for grades 6-8.
New Pricing (effective 08/27/2020)
Elementary School Breakfast (reduced) - $.30
Elementary School Breakfast (paid) - $1.75
Elementary School Lunch (reduced) - $.40
Elementary School Lunch (paid) - $3.25New Pricing (effective
08/27/2020)
Middle School Breakfast (reduced) - $.30
Middle School Breakfast (paid) - $1.75
Middle School Lunch (reduced) - $.40
Middle School Lunch (paid) - $3.50
We know that many families in our district qualify for the
National School Lunch Program (NSLP) and/or School Breakfast
Program (SBP) and choose not to participate. However, for us to
report accurate data about our District and to possibly qualify for
more grants or other funding opportunities, knowing how many
students qualify is critical. By filling out an application, even
if you do not want to participate in the federal meal programs, it
will help the San Bruno Park Elementary School District maintain
our funding.
A new application must be completed each school year for a child
to continue receiving meals under NSLP and/or SBP. Please read and
complete the application carefully. Incomplete applications cannot
be processed and will be returned to you to be completed. Please
note, that incomplete applications cause delays in the benefits
your child might receive. Families do not have to complete an
individual application for each child, even if one of the children
attends a different school within the District. Please fill out
only one application will all children in the family listed.
Students who participated in the program in the last school year
will keep their eligibility for 30 days to allow time for a new
application to be processed. Applications are available online:
Lunches can be paid online or via cash, cashiers’ check, or
money order by dropping it off at the District Office; attention
Gina Aguirre Food Services Coordinator. You will need to include
the full spelling of your child’s first and last name, and student
ID number.
For questions please contact Gina Aguirre at (650) 624-3127.
Estimados Padres de Familia:
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500 Acacia Avenue, San Bruno, CA 94066-4222
Tele: 650.624.3100
BOARD OF TRUSTEES:
Jennifer M. Blanco • Teri Chavez • Andrew T. Mason • Henry
Sanchez, M.D. • Andriana Shea
Jose Espinoza, Superintendent
El Distrito Escolar de San Bruno Park se le ha
requerido cumplir con la sección 205 de la Ley de Servicios de
Alimentos y Nutrición Infantil del 2010
(Ley Pública 111-296) lo cual incrementa gradualmente el precio
de los almuerzos escolares para las
familias que pagan. A partir del 27 de agosto del 2020 el precio
de los almuerzos pagados tendrán un
incremento de $0. 25 y los lonches tendrán un incremento de
$0.35 para grados K-5 y $0.50 para los
grados 6-8.
Nuevos Precios (effective 08/27/2020)
Elementary School Breakfast (reduced) - $.30
Elementary School Breakfast (paid) - $1.75
Elementary School Lunch (reduced) - $.40
Elementary School Lunch (paid) - $3. 25
Nuevos Precios (effective 08/27/2020)
Middle School Breakfast (reduced) - $.30
Middle School Breakfast (paid) - $1.75
Middle School Lunch (reduced) - $.40
Middle School Lunch (paid) - $3.50
Sabemos que muchas familias de nuestro distrito califican para
los programas National School Lunch
Program (NSLP) y/o School Breakfast Program (SBP) pero optan no
participar. Sin embargo, para
poder lograr la información correcta acerca nuestro distrito y
para poder calificar para fondos
adicionales y otras oportunidades, saber cuántos estudiantes
califican es crítico.
Una nueva solicitud debe ser completada cada año escolar para
que un niño continúe recibiendo
beneficios en el programa NSLP y/o SBP. Por favor, lea y
complete las solicitudes cuidadosamente. Las
solicitudes incompletas no pueden ser procesadas y serán
regresadas, cual retrasa los beneficios que su
hijo podrá recibir. Las familias no tienen que llenar uno
solicitud para cada estudiante de la familia que
asiste a la escuela en el Distrito Escolar de San Bruno Park,
incluso si los niños asisten a diferentes
escuelas. Solo una solicitud es necesaria con todos los niños de
la familia que se menciona. Estudiantes
que calificaron el ano escolar anterior mantendrán su
elegibilidad por 30 días para dar tiempo que se
procese una nueva solicitud.
Los almuerzos se pueden pagar, ya sea en el sitio web, en
efectivo, cheque de caja, giro postal o llevarlo
a la oficina del distrito, atención a Gina Aguirre Food Services
Coordinator. Necesitará incluir el
nombre completo del estudiante y el número de estudiantil de
identificación.
Se les requerirá que anoten el nombre completo de su niño y el
número de identificación. El dinero será
agregado a la cuenta de su niño en cuanto sea recibido por el
departamento de nutrición.
Si tiene alguna pregunta favor de comunicarse con Gina Aguirre
at (650) 624-3127.
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School Year 2020-2021 California Department of Education Pricing
Letter to Household & Instructions, Revised February 2017 Dear
Parent or Guardian: The San Bruno Park School District participates
in the National School Lunch Program and/or School Breakfast
Program. At San Bruno Park School District all students will
receive nutritious meals free of charge every school day. The meal
programs we participate in are supported by federal and state
reimbursements that are based on household income and eligibility.
We are able to serve free meals because households continue to
submit meal applications. Your cooperation is greatly appreciated.
You or your children do not have to be U.S. citizens to qualify for
free meals. If there are more household members than the number of
lines on the application, attach a second application. For a simple
and secure method to apply, use our online application at
SBPSD.ORG.
_________________ ____ ______ LETTER TO HOUSEHOLD FOR FREE AND
REDUCED-PRICE MEALS___________________________________________
QUALIFICATION: Your children may qualify for free or reduced-price
meals if your household income falls at or below the federal Income
Eligibility Guidelines below.
APPLYING FOR BENEFITS: An application for free or reduced-price
meals cannot be reviewed unless all required fields are completed.
A household may apply at any time during the school year. If you
are not eligible now, but your household income decreases,
household size increases, or a household member becomes eligible
for CalFresh, California Work Opportunity and Responsibility to
Kids (CalWORKs), or Food Distribution Program on Indian
Reservations (FDPIR) benefits, you may submit an application at
that time.
DIRECT CERTIFICATION: An application is not required if the
household receives a notification letter indicating all children
are automatically certified for free meals. If you did not receive
a letter,
please complete an application. VERIFICATION: School officials
may check the information on the application at any time during the
school year. You may be asked to submit information to validate
your income or current eligibility for CalFresh, CalWORKs, or FDPIR
benefits. WIC PARTICIPANTS: Households that receive Special
Supplemental Nutrition Program for Women, Infants, and Children
(WIC) benefits, may be eligible for free or reduced-price meals by
completing an application. HOMELESS, MIGRANT, RUNAWAY & HEAD
START: Children who meet the definition of homeless, migrant, or
runaway, and children participating in their school’s Head Start
program are eligible for free meals. Please contact school
officials for assistance at 650-624-3127. FOSTER CHILD: The legal
responsibility must be through a foster care agency or court to
qualify for free meals. A foster child may be included as a
household member if the foster family chooses to apply for their
non-foster children on the same application and must report any
personal income earned by the foster child. If the non-foster
children are not eligible, this does not prevent a foster child
from receiving free meals. FAIR HEARING: If you do not agree with
the school's decision
regarding your application’s determination or the result of
verification, you may discuss it with the hearing official. You
also have the right to a fair hearing, which may be requested by
calling or writing the following: Mariana Solomon, 500 Acacia Ave.,
650-624-3101. ELIGIBILITY CARRYOVER: Your child’s eligibility
status from the previous school year will continue into the new
school year for up to 30 operating days or until a new
determination is made. When the
carryover period ends, your child will be charged the full price
for meals, unless the household receives a notification letter for
free or reduced-price meals. School officials are not required to
send reminder or expired eligibility notices. NON-DISCRIMINATION
STATEMENT: In accordance with Federal civil rights law and U.S.
Department of Agriculture (USDA) civil rights regulations and
policies, the USDA, its Agencies, offices, and employees, and
institutions participating in or administering USDA programs are
prohibited from discriminating based on race, color, national
origin, sex, disability, age, or reprisal or retaliation for prior
civil rights activity in any program or activity conducted or
funded by USDA.
Persons with disabilities who require alternative means of
communication for program information (e.g. Braille, large print,
audiotape, American Sign Language, etc.), should contact the Agency
(State or local) where they applied for benefits. Individuals who
are deaf, hard of hearing or have speech disabilities may contact
USDA through the Federal Relay Service at (800) 877-8339.
Additionally, program information may be made available in
languages other than English.
To file a program complaint of discrimination, complete the USDA
Program Discrimination Complaint Form, (AD-3027) found online at:
http://www.ascr.usda.gov/complaint_filing_cust.html, and at any
USDA office, or write a letter addressed to USDA and provide in the
letter all of the information requested in the form. To request a
copy of the complaint form, call (866) 632-9992. Submit your
completed form or letter to USDA by: (1) Mail: U.S. Department of
Agriculture, Office of the Assistant Secretary for Civil Rights,
1400 Independence Ave SW, Washington, D.C. 20250-9410; (2) Fax:
(202) 690-7442; or (3) E-mail: [email protected].
This institution is an equal opportunity provider.
HOW TO APPLY FOR FREE OR REDUCED-PRICE MEALS – Complete one
application per household. Please print clearly with a pen.
Incomplete, illegible, or incorrect information will delay
processing. STEP 1: STUDENT INFORMATION – Include ALL STUDENTS who
attend San Bruno Park School District Print their name (first,
middle initial, last), school, grade level, and birthdate. If any
student listed is a foster child, check the “Foster” box. If you
are only applying for a foster child, complete STEP 1, and then
continue to STEP 4. If any student listed may be homeless, migrant,
or runaway, check the applicable “Homeless, Migrant, or Runaway”
box and complete all STEPS of the application. STEP 2: ASSISTANCE
PROGRAMS – If ANY household member (child or adult) participates in
CalFresh, CalWORKs, or FDPIR, then all children are eligible for
free meals. Must check the applicable assistance program box, enter
one case number, and then continue to STEP 4. If no one
participates, skip STEP 2 and continue to STEP 3. STEP 3: REPORT
INCOME FOR ALL HOUSEHOLD MEMBERS – Must report GROSS income (before
deductions) from ALL household members (children and adults) in
whole dollars. Enter “0” for any household member that does not
receive income.
A) Report the combined GROSS income for all students listed in
STEP 1 and enter the appropriate pay period. Include a foster
child’s income if you are applying for foster and non-foster
children on the same application.
B) Print the names (first and last) of ALL OTHER household
members not listed in STEP 1, including yourself. Report the total
GROSS income from each source and enter the appropriate pay
period.
C) Enter the total household size (children and adults). This
number MUST equal the listed household members from STEP 1 and STEP
3.
D) Enter the last four digits of your Social Security number
(SSN). If no adult household member has a SSN, check the “NO SSN”
box.
STEP 4: CONTACT INFORMATION & ADULT SIGNATURE – The
application must be signed by an adult household member. Print the
name of the adult signing the application, contact information, and
today’s date. OPTIONAL: CHILDREN’S ETHNIC AND RACIAL IDENTITIES –
This field is optional to complete and does not affect your
children’s eligibility for free or reduced-price meals. Please
check the appropriate boxes. INFORMATION STATEMENT: The Richard B.
Russell National School Lunch Act requires the information on this
application. You do not have to give the information, but if you do
not, we cannot approve your child for free or reduced-price meals.
You must include the last four digits of the social security number
of the adult household member who signs the application. The last
four digits of the social security number are not required when you
list a CalFresh, CalWORKs, or FDPIR case number or other FDPIR
identifier for your child or when you indicate that the adult
household member signing the application does not have a social
security number. We will use your information to determine if your
child is eligible for free or reduced-price meals, and for
administration and enforcement of the lunch and breakfast programs.
QUESTIONS/NEED ASSISTANCE: Please contact Gina Aguirre at
650-624-3127. SUBMIT: Please submit a complete application to your
child’s school or the nutrition office at 500 Acacia Ave., San
Bruno, CA. You will be notified if your application is approved or
denied for free or reduced-price meals. Sincerely, Gina Aguirre
Food Service Coordinator
http://www.ascr.usda.gov/complaint_filing_cust.htmlmailto:[email protected]
-
California Department of Education, February 2017
School Year 2020-2021 San Bruno Park School District Application
for Free and Reduced-Price Meals Complete one application per
household. Please read the instructions on how to apply. Print
clearly with a pen. You may also apply online at SBPSD.org. This
institution is an equal opportunity provider. California Education
Code Section 49557(a): Applications for free and reduced-price
meals may be submitted at any time during a school day. Children
participating in the federal National School Lunch Program will not
be overtly identified by the use of special tokens, special
tickets, special serving lines, separate entrances, separate dining
areas, or by any other means.
STEP 1 – STUDENT INFORMATION Children in Foster Care and
children who meet the definition of Homeless, Migrant, or Runaway
are eligible for free meals.
Print the name of EACH STUDENT (First, Middle Initial, Last)
Enter school name and grade level
Enter student’s birthdate Check the applicable box if the
student is foster, homeless, migrant, or runaway.
EXAMPLE: Joseph P Adams Lincoln Elementary 1st 12-15-2010 Foster
Homeless Migrant Runaway
STEP 2 – ASSISTANCE PROGRAMS: CalFresh, CalWORKs, or FDPIR Do
ANY household members (child or adult) currently participate in
CalFresh, CalWORKs or FDPIR? If NO, skip STEP 2 and continue to
STEP 3.
If YES, check the applicable program box, enter one case number,
skip STEP 3, and continue to STEP 4.
Select Program Type:
CalFresh CalWORKs FDPIR
Enter Case Number:
STEP 3 – REPORT INCOME FOR ALL HOUSEHOLD MEMBERS (Skip this step
if you answered ‘YES’ in STEP 2)
A. STUDENT INCOME: Sometimes students in the household earn
income. Enter the TOTAL GROSS income (before deductions) in whole
dollars earned by all students listed in STEP 1. Enter the
appropriate pay period in the “How
Often” box: W = Weekly, 2W = Biweekly, 2M = Twice a Month, M =
Monthly, Y = Yearly
Total Student Income How Often
$
B. ALL OTHER HOUSEHOLD MEMBERS (including yourself): List ALL
household members not listed in STEP 1, even if they do not receive
income. For each household member, report the TOTAL GROSS income
(before deductions) in whole dollars for each source. If the
household member does not receive income from any sources, write
“0”. If you enter “0” or leave any fields blank, you are certifying
(promising) that there is no income to report. Enter the
appropriate pay period in the “How Often” box: W = Weekly, 2W =
Biweekly, 2M = Twice a Month, M = Monthly, Y = Yearly
Print the name of ALL OTHER Household Members (First and
Last)
Earnings from Work How Often
Public Assistance/SSI/ Child Support/Alimony
How Often
Pensions/Retirement/All Other Income
How Often
$ $ $
$ $ $
$ $ $
$ $ $
C. Total Household Members (Children and Adults)
D. Enter the last four digits of Social Security number (SSN)
from the Primary Wage Earner or Other Adult Household Member
Check the box if
NO SSN
DO NOT COMPLETE. SCHOOL USE ONLY
How Often? Weekly Bi-Weekly Twice a Month Monthly Yearly Annual
Income Conversion: Weekly x52, Biweekly x26, Twice a Month x24,
Monthly x12
Total Household Income
$
Total Household Size
Eligibility Status: Free Reduced-price Paid (Denied)
Categorical
Verified as: Homeless Migrant Runaway Error Prone
Determining Official’s Signature: Date:
Confirming Official’s Signature: Date:
Verifying Official’s Signature: Date:
STEP 4 – CONTACT INFORMATION & ADULT SIGNATURE
Certification: I certify (promise) that all information on this
application is true and that all income is reported. I understand
that this information is given in connection with the receipt of
federal funds, and that school officials may verify (check) the
information. I am aware that if I purposely give false information,
my children may lose meal benefits, and I may be prosecuted under
applicable state and federal laws.
Signature of adult completing this application:
Print Name:
Date: Phone Number:
Mailing Address:
City: State: Zip:
E-mail:
OPTIONAL – CHILDREN’S ETHNIC AND RACIAL IDENTITIES We are
required to ask for information about your children’s race and
ethnicity. This information is important and helps to make sure we
are fully serving our community. Responding to this section is
optional and does not affect your children’s eligibility for free
or reduced-price meals.
Ethnicity (check one):
Hispanic or Latino Not Hispanic or Latino Race (check one or
more):
American Indian or Alaskan Native Asian Black or African
American Native Hawaiian or other Pacific Islander White
Binder2.pdfComprehensiveEnglish.pdfEnrollment Checklist
19-20.pdfStudent Registration Form 19-20Residency Affidavit
19-20Home Language Survey 19-20Health History Bilingual 19-20
Health Exam Letter 19-20Health Exam Letter 19-20.pdfHealth
Examination Form Bilingual 19-20.pdfPM171A - pg1
[email protected]_20190116_145330.pdfAcr589822854417280468019.tmpDental
Information 19-20Dental Information 19-20.pdfOral Health Assessment
Bilingual 19-20.pdf
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