Ducor Union Elementary School District

No matter what you selected above, please continue to answer the following by marking one or more boxes to indicate what you consider your race to be.

American Indian or Alaskan Native (100)

Chinese (201)

Japanese (202)

Korean (203)

Vietnamese (204)

Asian Indian (205)

Laotian (206)

Cambodian (207)

Hmong (208)

Other Asian (299)

Hawaiian (301)

Guamanian (302)

Samoan (303)

Tahitian (304)

Other Pacific Islander (399)

African American or Black (600)

White (700)

27) PARENT EDUCATION LEVEL: Check the response that describes the highest education level of parent/ guardian(s): Required*

Not a high school graduate

High School Graduate

Some college (includes AA degree)

College graduate

Graduate School/ Post Graduate Training

28) What special services has your child received? (Please check all boxes that apply) Required*

Resource (RSP)

Special Day Class (SDC)

Speech/ Language

504 Accommodation Plan

Gifted (GATE)

Remedial Math

Remedial Reading

Counseling

English Language Development

Medical Health Plan

29) Has the student been expelled or is the student in the process of being expelled from any school? Required*

Yes

30) If answered "Yes" to Q28, please provide the name of the school and location. (optional)

31) RESIDENCE — where is your child/family currently living? (Federally mandated by NCLB: Please check appropriate box) Required*

In a single family permanent residence (house, apartment, condo, mobile home)

In a motel/hotel

Doubled-up (sharing housing with other families/individuals due to economic hardship, loss, other)

Unsheltered (car/campsite)

In a sheltered or transitional housing program

Other

32) If answered "Other" to Q30, please share your student's current residence. (optional)

33) OTHER CHILDREN IN THE FAMILY Required*

Include FIRST NAME, LAST NAME, RELATIONSHIP, If the student lives at home or not, SCHOOL, and GRADE if applicable. Example: John Doe, Brother, Lives at home, Ducor Union Elementary, Grade 2

34) OTHER ADULTS IN THE HOME Required*

Include FIRST AND LAST NAME and RELATIONSHIP Example: Jane Doe, Aunt

35) MEDICAL CONDITIONS(Information not required for enrollment) (optional)

Diagnosed ADD or ADHD

Asthma

Bladder Problems

Bleeding Disorder

Color Vision Deficiency

Diabetes

Eczema/ Skin Trouble

History of Ear Problem

Heart Problem

Head Injury

History of Fractures

History of Hospitalization

History of Surgery

Known Hearing Loss

Known Vision Loss

Physical Limitations

Wears Contact Lens

Wears Glasses

Epilepsy

Eye Injury

Hypoglycemia

Frequent Nosebleeds

Scoliosis

Seizure Disorder

Chicken Pox

36) If student has medical conditions, please provide additional information on locations, and further details of conditions that the school should be made aware of. (optional)

37) ALLERGIES (Check all that apply) Required*

None

Animals

Insects

Bee Stings

Drugs

Food

Plants

Other

38) If student has allergies, please provide additional information. List specific items the student is allergic to, describe the allergic reaction, and/or treatment required. Required*

39) CURRENT MEDICATION(S) Required*

If medication is needed at school, a medication consent form must be picked up from the office and completed

None

Epi-Pen

Other

40) If answered "Other" to Q38, please share your student's medications. Include the dosage, time taken, and purpose of the medication. (optional)

41) EMERGENCY MEDICAL AUTHORIZATION: The undersigned declares under penalty of perjury that they are the parents or legal guardians of the named student and grant the above authorizations. Required*

If I, parent/guardian of the named student, are unable to be reached during any emergency, I hereby authorize a rep. of the school, pursuant to the provisions of Family Code Section 6910, to act as any agent to consent to the giving of any and all medical, dental, hospital, or surgical care to the named student. I have reviewed this 2 page document and to the best of my knowledge, the information contained herein is true and complete.

Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

42) HOME LANGUAGE SURVEY: Which language did your student learn when they first began to talk? Required*

43) HOME LANGUAGE SURVEY: What language does your student most frequently use at home? Required*

44) HOME LANGUAGE SURVEY: What language do you use most frequently to speak to your student? Required*

45) HOME LANGUAGE SURVEY: Name the language most often spoken by the adults at home? Required*

46) List (2) neighbors or nearby relatives who will assume temporary care of your child if you cannot be reached. Include FIRST and LAST NAME, ADDRESS, and PHONE NUMBER. Required*

47) List your student's babysitter and phone number if applicable. (optional)

48) In case of accident or serious illness, I request the school to contact me. If the school is unable to reach me, I hereby authorize the school to make whatever arrangements seem necessary. Required* Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

49) Please provide your Doctor's NAME and PHONE NUMBER Required*

50) PARENTAL ACKNOWLEDGEMENT ONLY Required*

Read the "Notice to Parents and Guardians" linked below and sign. By signing, you agree to the following terms. " I have received and read the notice regarding my rights relating to ten courses and activities which might affect my child." https://docs.google.com/document/d/1SDlpqzYzKo67XIIb-B5i6uakzy_BS2aJffpH99BBYf0/edit#bookmark=id.yiovw7p3mdmd

Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

51) PARENTAL CONSENT OR OBJECTION Required*

Read the "Notice to Parents and Guardians" linked below. If there are no objections, please sign. If you object to any item, please state items in Q52. I hereby consent for the current year, except that I object to items ________ (leave blank write in the number of the item, if any, to which you object). https://docs.google.com/document/d/1SDlpqzYzKo67XIIb-B5i6uakzy_BS2aJffpH99BBYf0/edit#bookmark=id.yiovw7p3mdmd

Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

52) Objection(s) to "Notice to Parents and Guardians" (optional)

If parents or guardians object to any items in from Q50-51, please provide the ITEM NUMBER and NAME OF CHILD Example: John Doe, Item 6

53) STUDENT TECH AGREEMENT: Read the "Student's Responsible Use of Technology Agreement" and sign below. Required*

https://docs.google.com/document/d/1SDlpqzYzKo67XIIb-B5i6uakzy_BS2aJffpH99BBYf0/edit#bookmark=id.d73qocl5mq1q

Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

54) PARENT TECH AGREEMENT: Read the "Student's Responsible Use of Technology" Agreement and sign below. Required*

https://docs.google.com/document/d/1SDlpqzYzKo67XIIb-B5i6uakzy_BS2aJffpH99BBYf0/edit#bookmark=id.d73qocl5mq1q

Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

55) STUDENT LAPTOP AGREEMENT: Read the "Student/Parent Laptop Agreement" and sign below Required*

https://docs.google.com/document/d/1SDlpqzYzKo67XIIb-B5i6uakzy_BS2aJffpH99BBYf0/edit#bookmark=id.v090wj4sofk3

Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

56) PARENT LAPTOP AGREEMENT: Read the "Student/Parent Laptop Agreement" and sign below Required*

https://docs.google.com/document/d/1SDlpqzYzKo67XIIb-B5i6uakzy_BS2aJffpH99BBYf0/edit#bookmark=id.v090wj4sofk3

Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

57) Review the "Ducor Union School District Referral Questionnaire" and if applicable, provide the following information. Required*

https://docs.google.com/document/d/1SDlpqzYzKo67XIIb-B5i6uakzy_BS2aJffpH99BBYf0/edit#bookmark=id.36g0havwwj48 Parent/Guardian Name Current Address, City, State, Zip Phone Number First and Last Name of Student

58) STUDENT SIGNATURE: Read the "School- Parent Compact" and sign below. Required*

https://docs.google.com/document/d/1SDlpqzYzKo67XIIb-B5i6uakzy_BS2aJffpH99BBYf0/edit#bookmark=id.4wwjojh2z8v7

Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

59) PARENT SIGNATURE: Read the "School- Parent Compact" and sign below. Required*

https://docs.google.com/document/d/1SDlpqzYzKo67XIIb-B5i6uakzy_BS2aJffpH99BBYf0/edit#bookmark=id.4wwjojh2z8v7

Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

60) ACTIVITY PERMIT: Read the "Activity Permit" and check the activities below that you grant permission for your child to attend Required*

https://docs.google.com/document/d/1SDlpqzYzKo67XIIb-B5i6uakzy_BS2aJffpH99BBYf0/edit#bookmark=id.43p42psr0f47

Field Trips

ANY School Athletics

Other School Sponsored Activities

61) ACTIVITY PERMIT: Do you have a personal accident insurance policy for your child other than accidental insurance provided bu the school? Required*

Yes

62) ACTIVITY PERMIT: If you do have an insurance policy for your child other than accidental insurance provided by the school, please provide the insurance company AND policy number (optional)

63) ACTIVITY PERMIT: Please list any medical problems your student has Required*

64) ACTIVITY PERMIT: Please list any medications your student is allergic to Required*

65) ACTIVITY PERMIT: Please provide the name and phone number of your student's doctor Required*

66) ACTIVITY PERMIT: Please read the statement below and sign Required*

In case of an accident of serious illness, I request the school to contact me. If the the school is unable to reach me, I hereby authorize the school to make whatever arrangements seem necessary.

Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

67) MEDICATION FORM: Please review the "Medication Form" and acknowledge you have read the form by signing below. Required*

https://docs.google.com/document/d/1SDlpqzYzKo67XIIb-B5i6uakzy_BS2aJffpH99BBYf0/edit#bookmark=id.qkw82cejpwm3

Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

68) AUTHORIZATION FOR PRESCRIBED AND OVER THE COUNTER MEDICATION: Please review the "Authorization for Prescribed and Over the Counter Medication" and acknowledge you have read the form by signing below Required*

https://docs.google.com/document/d/1SDlpqzYzKo67XIIb-B5i6uakzy_BS2aJffpH99BBYf0/edit#bookmark=id.3qaxkqot6h5g

Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

69) STUDENT: AUTHORIZATION AND PROTOCOL FOR SELF-ADMINISTERED MEDICATION: Please review the link below and acknowledge you have read the form by signing below Required*

https://docs.google.com/document/d/1SDlpqzYzKo67XIIb-B5i6uakzy_BS2aJffpH99BBYf0/edit#bookmark=id.wi90yaih8ywl

Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

70) GUARDIAN: AUTHORIZATION AND PROTOCOL FOR SELF-ADMINISTERED MEDICATION: Please review the link below and acknowledge you have read the form by signing below Required*

https://docs.google.com/document/d/1SDlpqzYzKo67XIIb-B5i6uakzy_BS2aJffpH99BBYf0/edit#bookmark=id.wi90yaih8ywl

Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

71) GUARDIANS: Please review the link below and acknowledge you have read the form by signing below Required*

https://docs.google.com/document/d/1SDlpqzYzKo67XIIb-B5i6uakzy_BS2aJffpH99BBYf0/edit#bookmark=id.i1noc2uqnna8

Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

72) DUCOR EIEMENTARY SCHOOL SCHOOL NURSE HEALTH AND EMERGENCY INFORMATION Required*

https://docs.google.com/document/d/1SDlpqzYzKo67XIIb-B5i6uakzy_BS2aJffpH99BBYf0/edit#bookmark=id.lgbt39n7t6ld

Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

73) CURRENT HEALTH INFORMATION: Is there a health condition which should be brought to the attention of the school nurse? Required*

YES

74) IF YES TO Q73, PLEASE EXPLAIN Required*

75) IS PHYSICAL ACTIVITY LIMITED? According to the California State Code a statement must be submitted in writing each year if activity is limited. Required*

YES

76) California State Code requires a parent/guardian to inform the school of continuing medication being taken, current dosage, and name of supervising physician: Required*

77) NAME OF MEDICAL INSURANCE COMPANY Required*

78) IS YOUR INSURANCE MEDI-CAL? Required*

YES

79) PLEASE READ ATTACHED LINK AND SIGN BELOW. Required*

https://docs.google.com/document/d/1SDlpqzYzKo67XIIb-B5i6uakzy_BS2aJffpH99BBYf0/edit#bookmark=id.45w77fomf2c

Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

80) MEDIA RELEASE: PLEASE READ AND SIGN BELOW Required*

https://docs.google.com/document/d/1SDlpqzYzKo67XIIb-B5i6uakzy_BS2aJffpH99BBYf0/edit#bookmark=id.mjtbdycw3pc5

Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

Ducor Union Elementary School District
Forms

Forms

2023 - 2024 Parent/Guardian Contact Information

Maintenance/Repair Request

Tech Request

Updated Contact Information

5 forms were found.

Find Us

Ducor Union Elementary School District23761 Avenue 56Ducor, California 93218559-534-2261559-534-2271ducorelementary@ducor.k12.ca.us