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.
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
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 ________________
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 ________________
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.
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:_______________________________
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
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
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/
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
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.
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:
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.
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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