San Juan Unified School District EARLY CHILDHOOD EDUCATION Preschool & Infant/Toddler Registration REQUIRED DOCUMENTATION FOR ENROLLMENT The following is a partial list of documentation required to enroll in Head Start or State Preschool: Proof of residency in the San Juan Unified School District, which includes: o Current utility bill (SMUD / PG&E / Water) OR Lease/rental agreement / mortgage statement. NOTE: If you reside with someone else, you will need an Affidavit of Residency, which can be obtained at our office. Child’s original, certified birth certificate. NOTE: For State Preschool you are required to provide a certified birth certificate for each child in the family. Most current and consecutive 30 days of any / all income documentation such as check stubs, disability, SSI / TANIF / CalWORKS statements. Child’s personal immunization record or documentation with at least: 3 Polio (OPV/IPV), 4 DTP, 3 Hepatitis B, 1 Varicella, and 1 MMR, & 1 Hib both given on or after their 1st Birthday. Each child is required to have a TB clearance from their medical provider either on a Physical Exam form, a letter stating the child is free from TB, or a negative TB skin test, chest x-ray or Quantiferon (QFT) blood test. MediCal, Cal Fresh (Food Stamps) or WIC case numbers - if applicable Physical Exams that have been done within 12 months of enrollment (form attached) Dental Exams (for preschool aged students) that have been done within 12 months of enrollment (form attached, if applicable) Court documents for guardianship / foster care / custody IEP documentation, Health Issues documentation; including but not limited to Allergy Statement, Asthma, Medication in School, Food Prohibition forms, if applicable. Other program specific documentation to be determined by Admissions and Family Services Technician if / when you are contacted to schedule an appointment. For more information, please email [email protected]or visist www.sanjuan.edu/preschool Please understand each family is responsible for updating their eligibility and contact information if it changes as it may adjust where you are ranked on our Eligibility List. To ensure your child remains active on the SJ-ECE Eligibility List, please update your information every 6 months
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San Juan Unified School District
EARLY CHILDHOOD EDUCATION
Preschool & Infant/Toddler Registration
REQUIRED DOCUMENTATION FOR ENROLLMENT The following is a partial list of documentation required to enroll in Head Start or State Preschool:
Proof of residency in the San Juan Unified School District, which includes: o Current utility bill (SMUD / PG&E / Water) OR Lease/rental agreement / mortgage
statement.NOTE: If you reside with someone else, you will need an Affidavit of Residency, whichcan be obtained at our office.
Child’s original, certified birth certificate. NOTE: For State Preschool you are required to provide a certified birth certificate for each child in the family.
Most current and consecutive 30 days of any / all income documentation such as check stubs, disability, SSI / TANIF / CalWORKS statements.
Child’s personal immunization record or documentation with at least: 3 Polio (OPV/IPV), 4 DTP, 3 Hepatitis B, 1 Varicella, and 1 MMR, & 1 Hib both given on or after their 1st Birthday.
Each child is required to have a TB clearance from their medical provider either on a Physical Exam form, a letter stating the child is free from TB, or a negative TB skin test, chest x-ray or Quantiferon (QFT) blood test.
MediCal, Cal Fresh (Food Stamps) or WIC case numbers - if applicable
Physical Exams that have been done within 12 months of enrollment (form attached)
Dental Exams (for preschool aged students) that have been done within 12 months of enrollment (form attached, if applicable)
Court documents for guardianship / foster care / custody
IEP documentation, Health Issues documentation; including but not limited to Allergy Statement, Asthma, Medication in School, Food Prohibition forms, if applicable.
Other program specific documentation to be determined by Admissions and Family Services Technician if / when you are contacted to schedule an appointment.
Please understand each family is responsible for updating their eligibility and contact information if it changes as it may adjust where you are ranked on our Eligibility List.
To ensure your child remains active on the SJ-ECE Eligibility List, please update your information every 6 months
Spanish Distrito Escolar Unificado De San Juan
EDUCACIÓN DE LA PRIMERA INFANCIA
Inscripción Preescolar y Infantil
DOCUMENTACIÓN REQUERIDA PARA INSCRIPCIÓN
Lo siguiente es una lista parcial de la documentación que se requiere para inscribir en Head Start o Preescolar Estatal:
Prueba de domicilio en el Distrito Escolar de San Juan, lo cual incluye:
La factura de servicios más recientes (Luz/Gas/Agua) O contrato de renta/cédulahipotecariaNOTA: Si vive con otra persona, necesita un Afidávit de Residencia, que se puedeobtener en nuestra oficina.
Acta de Nacimiento original, certificada del niño(a). NOTA: Para Preescolar Estatal, se
requiere que proporcione un acta de nacimiento certificado por cada niño(a) en la familia.
Los documentos de ingreso más recientes de 30 días y consecutivos (un mes completo)
tal como talones de cheque, disability, recibos de SSI/TANF/CalWORKS.
Tarjeta de vacunas (o documento del doctor) con lo siguiente: 3 polio (OPV/IPV), 4 DPT, 3Hepatitis B,1 varicela; más 1 HIB y 1 MMR dado después de su primer cumpleaños.
A cada niño se le exige que obtenga una autorización de Tuberculosis (TB) de su proveedor médico en el Formulario de Examen Físico, una carta en la que se indique que el niño está libre de tuberculosis, o una prueba cutánea negativa de TB, o una radiografía de tórax o análisis de sangre de Quantiferon (QFT).
Número de caso MediCal, Cal Fresh/Food Stamps (Estampillas de comida) , WIC tarjeta o libro -si se aplica
Examen físico y dental dentro de los últimos 12 meses del primer día escolar de su hijo(a).
(formularios adjuntos). (ej.: si la escuela empieza 8/27/12, el físico está al día si se hizo después del 8/27/11)
Documentos de la corte de tutela / crianza provisional (Foster Care)/ custodia.
Documentación de IEP, Declaración de Alergia, Asma, Administración de medicamento en
la escuela, formulario de Comidas Prohibidas, si se aplica.
Otra documentación específica al programa será determinada por la persona encargada de inscripciones si o cuando se comuniquen con usted para hacer una cita para matriculación.
Por favor entienda que cada familia es responsable de renovar sus datos de contacto y su información de
elegibilidad ya que puede cambiar su rango en la lista.
Para asegurarse que su niño(a) continúe activo(a) en la lista de elegibilidad de SJ-ECE
por favor llame al número de abajo cada seis meses para actualizar su información.
W:\Marshall\ECE\Health\Items ON ONE DRIVE\Health Forms\Health Forms -2021\Preschool PE
DOB: □ M □ F
Lead Risk AssessmentDate:
□ Not at Risk□ At Risk
Blood Lead test required
Blood Lead Test (One result required
ON or AFTER 24 months)
Date: Result
Hematocrit or Hemoglobin (Due Yearly)
Date: Result□ Not at Risk
□ No □ Yes
Exam Results Normal Abnormal Not evaluated
General Appearance DateHead RightEyes Left
Ears, Nose & Throat
Teeth/Gums
HeartLungs
Abdomen
GenitourinarySkin Date
Posture/Gait Right □ No □ YesNeurologic (Gross, Fine
motor, etc.) LeftDevelopmental Both
Speech □ No □ YesBehavioral
Diet/Nutrition □ No □ Yes
Findings from above:
Health Concerns/ Diagnoses:
Medications Taken At Home:
□ No□ Yes
Medication required at
school?
□ No□ Yes
□ Yes
________________________________________
__________________
________________________________________
Date of Exam Height Weight BP
PLEASE ATTACH COPY OF IZ
RECORDNote: HIB required on or
after 1st birthday for childcare for < 5 yrs of
age
Hearing Screening (25dB at 1000, 2000, 4000 Hz)
□ Pass □ Fail□ Pass □ Fail
San Juan Unified School District - Early Childhood EducationFAX 916-971-5993
PRESCHOOL PHYSICAL EXAM (TO BE COMPLETED BY PROVIDER)
REQUIRED FOR PRESCHOOL PROGRAMS
AllergiesPHYSICAL EXAM RESULTS
Lactose Intolerant?
ATTENTION PROVIDER: Head Start Programs requires a COMPLETE CHDP EQUIVALENT HEALTH EXAM, including BLOOD LEAD TEST. Documentation of all screenings is necessary to provide prompt assistance to families and better meet the health and developmental needs of the child. Please complete ALL boxes, sign, date and return to parent.
List any treatment/follow up:
Date: □ Not at Risk
TB Risk Assessment
List any treatment/follow up:
□ QuantiFERON
CHILD NAME: ________________________________
□ TST/PPD
Dental
Fluoride Applied?
Fluoride Prescribed?
20/
20/ 20/
SCHOOL: _________________
Date of reading:
Referral made?
Reason:
Concerns
□ NKALIST: ________________________________ □ Life threatening
Vision Acuity Screening
Date of Test:
List any treatment/follow up:
Immunizations UTD
□ Yes□ No
□ Unable to test
□ Unable to test
Updated March 2021
Result: □ Negative□ Positive
Concerns
□ No, explain:
Treatment, Restrictions, Recommendations for School:
Date:
PRINT Provider Name:
CLINIC STAMP
□ At RiskTB test
required
List List meds at school - Need Med Form:
Full participation in normal daily activities at school is recommended (if no, explain in space provided):
Health Care Provider Signature:
PRESCHOOL
Please list recommended services in order on the table below and restoration you performed:
Early Childhood Education
Division of Teaching & Learning 5309 Kenneth Avenue, Carmichael, California 95608 Telephone (916) 971-7375; FAX (916) 971-5993 Internet Web Site: www.sanjuan.edu/EarlyChildhoodEducation
DENTAL RECORD
School: _________________________________
Child’s Name: Birth Date: Sex: M F Parent’s Name: Phone: Address: I authorize professionally qualified individuals to exchange information about my child. I understand that all information will be kept in a confidential file. Parent/Guardian Signature: Date:
Date of Exam: _________________________
Cleaning and fluoride treatment date completed: _____________
In diagram above indicate oral conditions before treatment: Missing Decayed Filled
CHILD ORAL HEALTH SUMMARY
Dental Needs: Problems Noted: Routine Recall Visits Special Home Emphasis, Oral Hygiene Dietary Harmful Oral Habit(s) Developmental Other ______________
All Planned Treatments:
Is Complete Is Not Complete. Please explain and check what needs to be completed: Treatment (Restoration, Pulp Therapy, Extraction) X-Rays Cleaning Fluoride Other __________________________ Number of Visits Needed: _________ Treatment Referral to: ______________________________________________ Phone______________________
