2017-2018 STATE PRESCHOOL Registration Requirements
2017-2018 STATE PRESCHOOL Registration Requirements & Application EARLY BIRD REGISTRATION will begin on March 21, 2017 through April 28, 2017 Applications are accepted in person or by fax Please Note: All required documents MUST be submitted with the application Preschool Office Hours are Monday through Friday between 8:00 a.m. and 4:00 p.m. QUALIFICATIONS – A CHILD MUST ● Turn four (4) years of age between December 3, 2016 & December 2, 2017 of the school year from July 1, 2017 to June 30, 2018 Your child’s birthdate must be between December 3, 2012 and December 2, 2013 ● Be completely toilet trained and be able to use the restroom independently ● Have a current California Tuberculosis Risk Assessment dated after the last birthdate along with all immunizations ● Have a current physical examination report after the last birthdate AND THE FAMILY MUST ● Live in Central Unified School District ● The applicant must be the adult who is responsible in providing the care & welfare for the preschooler ● Qualify by the State Guideline as listed in the table below - If over income, you will be denied ● Provide own transportation to and from school - No bus is available STATE INCOME GUIDELINES Effective 1-1-09-CDE – Management Bulletin 08-17 (Subject to Change)
Your family income must be at or below the state guideline listed below to qualify # of Persons in Family
Gross Monthly Income
Family Yearly Income
1-2 3 4 5 6 7
$3,283.00 $3,518.00 $3,908.00 $4,534.00 $5,159.00 $5,276.00
$39,396.00 $42,216.00 $46,896.00 $54,408.00 $61,908.00 $63,312.00
PLACEMENT GUIDELINES
Placement into a class is based on your eligibility ranking, according to income and family size, established by the State of
California; Placement is NOT on a first come, first served basis First priority is given to Protective Service Children and At-Risk Children Second priority is given to those children whose birthdays are between December 2, 2012 and September 1, 2013 Priority of your child’s enrollment can change at any time depending on your eligibility and the eligibility of other families Applications received during Early Bird Registration (March 21, 2017 – April 28, 2017) will be given priority over applications received after April 28, 2017 If your application is accepted and an opening is available, you will be contacted by phone or email to schedule an appointment to complete the Registration and Enrollment Paperwork If your application is not accepted after review, you will be notified by mail
ONE (1) COPY OF ALL OF THE FOLLOWING DOCUMENTS MUST BE SUBMITTED WITH YOUR APPLICATION
Birth Certificates of ALL your children (under 18) living in the home Proof of Address from Parent(s) Living With The Child – A copy of the most recent Utility Bill, Mortgage Statement or Rental/Lease Agreement with prior month receipt of payment to show that you are the responsible party in the care & welfare needs of the preschool child & siblings o If the above documents are not in your name, but you live with someone who owns the house and the utilities are in their name; the homeowner must complete and sign the attached Self-Declaration Under Penalty of Perjury form stating they are not responsible for the care & welfare needs of the preschooler’s family and the Homeowner must provide a copy of their recent Utility Bill, Mortgage Statement or Rental/Lease Agreement with prior month receipt of payment Immunization Record – The preschool child’s immunizations must be current along with a current California Tuberculosis Risk Assessment dated after the last birthdate Physical Examination – The preschool child’s physical examination report must have been given within the past year. If you do not have a copy, please have your child’s doctor complete the attached Physician’s Report form. Note: A current physical report must be provided on a yearly basis Driver’s License/ID of parent(s)/guardian(s) enrolling the preschool child FOR CHILDREN LIVING WITH A GUARDIAN OR FOSTER PARENTS ONLY: Caregiver Affidavit – If child’s caretaker is a Foster Child and/or Guardianship Foster Parent’s Agreement (SOC 156) and/or court order “Appointing guardian of Minor & Certified Home Agreement” must be submitted and processed in the Student Support Services Department at Central Unified School District Office, 5652 W. Gettysburg Ave, Room 13. Please call 274-4700 ext. 63138, for any questions regarding the Caregiver Affidavit
PRESCHOOL OFFICE Address: 5652 W. Gettysburg, Room 10 Fresno, CA 93722 Phone: (559) 274-4700 Ext 63199 Fax: (559) 277-4527
CENTRAL UNIFIED SCHOOL DISTRICT 4605 North Polk Avenue · Fresno, CA 93722 Phone: (559) 274-4700 · Fax: (559) 271-8200
BOARD OF TRUSTEES Richard Atkins Phillip Cervantes Rubén Coronado Terry Cox Rama Dawar Cesar Granda Richard A. Solis SUPERINTENDENT Mark G. Sutton
February 6, 2017
Dear Parent or Guardian: Re: Immunization Requirements for 2017 Under a new law known as SB 277, beginning January 1, 2016, exemptions based on personal beliefs are no longer an option for the vaccines that are currently required for entry into child care or school in California. Most families will not be affected by the new law because their children have received all required vaccinations. Personal beliefs exemptions on file for a child already attending child care or school will remain valid until the child reaches the next immunization checkpoint at kindergarten (including transitional kindergarten) or 7th grade. For more information about SB 277, please see the Frequently Asked Questions available at: http://www.shotsforschool.org/laws/sb277faq/. For more information about school immunization requirements and resources, please visit the California Department of Public Health’s website at www.shotsforschool.org, or contact Fresno County Health Department Immunizations at (559) 600-3550. Thank you for helping us to keep our children and community healthy. Sincerely,
Janene Armas, RN, BSN, PHN Coordinator of Health Services Central Unified School District
District Administration Laurel Ashlock, Ed.D, Assistant Superintendent, Chief Academic Officer · Ketti Davis, Assistant Superintendent, Professional Development Jack Kelejian, Assistant Superintendent, Human Resources · Kelly Porterfield, Assistant Superintendent, Chief Business Officer Paul Birrell, Director, 7-12 and Adult Education · Tami Boatright Ed.D, Director, K-8 Education · Andrea Valadez, Administrator, Special Education & Support Services
CALIFORNIA IMMUNIZATION REQUIREMENTS FOR PRESCHOOL ENROLLMENT
Your child must have the immunizations listed below to attend Preschool A copy of your child’s Immunization Record must be provided along with your application as proof of immunization If your child has not received the Tuberculosis Skin Test (PPD), then a current California Tuberculosis Risk Assessment dated after the last birthdate must be submitted along with the immunizations
Vaccines
Required Dose(s) To Attend Preschool
Polio
3 doses – After age 4…if last one given before 2nd birthday, will need the 4th dose
DTP/DPaP/DT/Td
4 doses – After age 4…if last one given before 2nd birthday, will need the 5th dose
MMR (Measles, Mumps, Rubella)
1 dose – Must be given on or after the 1st birthday - **After age 4, will need 2nd dose 1 dose – Last dose must be given on or after the 1st birthday – If no dose given, one dose required until 4 ½ yrs. old
Hib Meningitis
3 doses (3 dose series)
Hepatitis B
1 dose – Must be given on or after the 1st birthday or Health Care Provider must document if child has had chickenpox and shot will not be required
Varicella
Tuberculosis Skin Test (PPD)
1 dose – Must be given within one year of entry into school (after August 1st of last year & before August of this year
To obtain immunizations, contact your Authorized Health Care Provider, Local Health Clinics or The Fresno County Department of Community Health Immunization Clinic. If your child’s immunizations are not up-to-date, parents will need to make an appointment prior to the Registration.
If you do not have private insurance, you may contact:
Fresno County Department of Health 1221 Fulton Mall - First Floor Phone: 600-3550 Parent or legal guardian must be present Bring your child’s immunization card or shot record Bring Medi-Cal Card Immunizations will be given on a first-come, first served basis Walk Ins - Monday and Wednesday from 8:00 am to 11:00 am and 1:00 pm to 3:00 pm
If you do have private insurance, you may contact: Clinic Sierra Vista - Fresno locations: 457-5800 (Appointment Needed) United Health Clinics - Kerman: 846-6330 Valley Health Team - Kerman: 846-9359
Parent or legal guardian must be present Bring your child’s immunization card or shot record Bring Proof of Health Insurance Clinics provide Medical and Dental Care options
(Closed 12:00 to 1:00 for lunch)
FOR CALIFORNIA TUBERCULOSIS RISK ASSESSMENTS ONLY
You may call the School Nurse at any district school site to schedule an appointment Imm Req 3/17
Declaration Under Penalty of Perjury
(Declaration of Residency)
I _______________________________________am not responsible for the care and welfare Name of Owner of Home
for ______________________________________ and her/his child(ren) __________________ Name(s) of Preschooler’s Parent(s)
List Name(s) of Child(ren)
______________________________________________________________who live with me at _____________________________________________________________________________. Street Address
City
Zip Code
NOTE: Must bring current PG&E bill with the same name as listed above of owner of home and address with this form.
I declare under penalty of perjury that the above information is true and correct to the best of my knowledge. _________________________________
__________________________
Signature
Date
Declaración Bajo Pena de Perjurio (Declaración de Residencia)
Yo _______________________________________no soy responsable del cuidado y el Nombre de Propietario de la Casa
bienestar de ________________________________________________________ y los niño(s) Nombre(s) de los Padre(s) del Niño
______________________________________________________________que vive con migo Nombre(s) de los Niño(s)
en __________________________________________________________________________. Dirección de la Casa
Ciudad
Código Postal
NOTA: Debe traer cuenta de la luz (PG&E) con el mismo nombre como listó arriba de propietario de la casa y la dirección con esta forma
Declaro bajo pena de perjurio que la información anterior es verdadera y correcta a lo mejor de mi conocimiento. _________________________________
__________________________
Firma
Fecha Declaration Under Perjury 11/14
Received Date
2017-2018 STATE PRESCHOOL APPLICATION PRESCHOOL CHILD’S NAME ________________________________________ Birth Date________________ Is the preschool child fully toilet trained? Yes
Are there any special needs or concerns regarding your child? If so, please explain:
No
Enrolling Parent/Guardian__________________________________________________________
Mother
Father
Guardian
Foster Parent
Cell # ___________________________________ Work # ___________________________________ Home # ___________________________________ Email Address: ________________________________________________________________________________________________________________ Enrolling Parent/Guardian__________________________________________________________
Mother
Father
Guardian
Foster Parent
Cell # ___________________________________ Work # ___________________________________ Home # ___________________________________ Email Address: ________________________________________________________________________________________________________________ Parent Marital Status:
Married
Is Father In The Home?
Yes
Divorced No
Domestic Partnership
Single
Is Mother In The Home?
Yes
Separated
Common-Law
Widow/Widower
No
Who is responsible in providing the care & welfare for the preschooler? Mother
Foster Mother
Father
Foster Father
Boyfriend
Girlfriend
Guardian
Grandfather
4 Digit Code
Grandmother
Home Address: ______________________________________________________ City_________________ Zip Code_______________ Mailing Address/P.O. Box: _____________________________________________ City_________________ Zip Code_______________ FAMILY SIZE INFORMATION – List ALL CHILDREN residing in the home and counted in the family size Full Name of Child Including Middle Initial M/F Birth Date Full Name of Child Including Middle Initial
M/F
Birth Date
FAMILY INCOME INFORMATION What is Father/Guardian’s Gross Monthly Income $ ______________ Is Father/Guardian Employed? Yes No Do you get paid by check or cash? Check Cash How often do you get paid? Weekly
Bi-Weekly
2X’s Per Month
Monthly
What is Mother/Guardian’s Gross Monthly Income $ ______________ Is Mother/Guardian Employed? Yes No Do you get paid by check or cash? Check Cash How often do you get paid? Weekly
Bi-Weekly
2X’s Per Month
Monthly
Is Father/Guardian receiving Cash Aid? Yes No Amount of Monthly Cash Aid received: $______________
Is Mother/Guardian receiving Cash Aid? Yes No Amount of Monthly Cash Aid received: $______________
Does Father/Guardian receive additional monetary benefits/support? Yes No If yes, which type:________________________________ Amount of benefits/support received: $______________
Does Mother/Guardian receive additional monetary benefits/support? Yes No If yes, which type:________________________________ Amount of benefits/support received: $______________
If you have NO INCOME, please explain how you support your family on a monthly basis: ______________________________________________
If you have NO INCOME, please explain how you support your family on a monthly basis: ________________________________________________________
PRESCHOOL SITES BIOLA-PERSHING: CENTRAL DEMONSTRATION: HERNDON BARSTOW: MADISON: TEAGUE:
CLASS TIMES AM (8:30-11:30) or PM (12:30-3:30) AM (8:00-11:00) or PM (12:00-3:00) AM (8:45-11:45) or PM (12:45-3:45) AM (8:30-11:30) or PM (12:30-3:30) AM Not Available PM (12:45-3:45)
LIST PRESCHOOL SITE CHOICES
CIRCLE CLASS TIME PREFERENCE
#1 ______________________________
AM
PM
NO PREFERENCE
#2 ______________________________
AM
PM
NO PREFERENCE
#3 ______________________________
AM
PM
NO PREFERENCE
#4 ______________________________
AM
PM
NO PREFERENCE
Your family income must be at or below the state guideline listed below to qualify # of Persons in Family
Gross Monthly Income
Family Yearly Income
1-2 3 4 5 6 7
$3,283.00 $3,518.00 $3,908.00 $4,534.00 $5,159.00 $5,276.00
$39,396.00 $42,216.00 $46,896.00 $54,408.00 $61,908.00 $63,312.00
PLACEMENT GUIDELINES
Placement into a class is based on your eligibility ranking, according to income and family size, established by the State of
California; Placement is NOT on a first come, first served basis First priority is given to Protective Service Children and At-Risk Children Second priority is given to those children whose birthdays are between December 2, 2012 and September 1, 2013 Priority of your child’s enrollment can change at any time depending on your eligibility and the eligibility of other families Applications received during Early Bird Registration (March 21, 2017 – April 28, 2017) will be given priority over applications received after April 28, 2017 If your application is accepted and an opening is available, you will be contacted by phone or email to schedule an appointment to complete the Registration and Enrollment Paperwork If your application is not accepted after review, you will be notified by mail
ONE (1) COPY OF ALL OF THE FOLLOWING DOCUMENTS MUST BE SUBMITTED WITH YOUR APPLICATION
Birth Certificates of ALL your children (under 18) living in the home Proof of Address from Parent(s) Living With The Child – A copy of the most recent Utility Bill, Mortgage Statement or Rental/Lease Agreement with prior month receipt of payment to show that you are the responsible party in the care & welfare needs of the preschool child & siblings o If the above documents are not in your name, but you live with someone who owns the house and the utilities are in their name; the homeowner must complete and sign the attached Self-Declaration Under Penalty of Perjury form stating they are not responsible for the care & welfare needs of the preschooler’s family and the Homeowner must provide a copy of their recent Utility Bill, Mortgage Statement or Rental/Lease Agreement with prior month receipt of payment Immunization Record – The preschool child’s immunizations must be current along with a current California Tuberculosis Risk Assessment dated after the last birthdate Physical Examination – The preschool child’s physical examination report must have been given within the past year. If you do not have a copy, please have your child’s doctor complete the attached Physician’s Report form. Note: A current physical report must be provided on a yearly basis Driver’s License/ID of parent(s)/guardian(s) enrolling the preschool child FOR CHILDREN LIVING WITH A GUARDIAN OR FOSTER PARENTS ONLY: Caregiver Affidavit – If child’s caretaker is a Foster Child and/or Guardianship Foster Parent’s Agreement (SOC 156) and/or court order “Appointing guardian of Minor & Certified Home Agreement” must be submitted and processed in the Student Support Services Department at Central Unified School District Office, 5652 W. Gettysburg Ave, Room 13. Please call 274-4700 ext. 63138, for any questions regarding the Caregiver Affidavit
PRESCHOOL OFFICE Address: 5652 W. Gettysburg, Room 10 Fresno, CA 93722 Phone: (559) 274-4700 Ext 63199 Fax: (559) 277-4527
CENTRAL UNIFIED SCHOOL DISTRICT 4605 North Polk Avenue · Fresno, CA 93722 Phone: (559) 274-4700 · Fax: (559) 271-8200
BOARD OF TRUSTEES Richard Atkins Phillip Cervantes Rubén Coronado Terry Cox Rama Dawar Cesar Granda Richard A. Solis SUPERINTENDENT Mark G. Sutton
February 6, 2017
Dear Parent or Guardian: Re: Immunization Requirements for 2017 Under a new law known as SB 277, beginning January 1, 2016, exemptions based on personal beliefs are no longer an option for the vaccines that are currently required for entry into child care or school in California. Most families will not be affected by the new law because their children have received all required vaccinations. Personal beliefs exemptions on file for a child already attending child care or school will remain valid until the child reaches the next immunization checkpoint at kindergarten (including transitional kindergarten) or 7th grade. For more information about SB 277, please see the Frequently Asked Questions available at: http://www.shotsforschool.org/laws/sb277faq/. For more information about school immunization requirements and resources, please visit the California Department of Public Health’s website at www.shotsforschool.org, or contact Fresno County Health Department Immunizations at (559) 600-3550. Thank you for helping us to keep our children and community healthy. Sincerely,
Janene Armas, RN, BSN, PHN Coordinator of Health Services Central Unified School District
District Administration Laurel Ashlock, Ed.D, Assistant Superintendent, Chief Academic Officer · Ketti Davis, Assistant Superintendent, Professional Development Jack Kelejian, Assistant Superintendent, Human Resources · Kelly Porterfield, Assistant Superintendent, Chief Business Officer Paul Birrell, Director, 7-12 and Adult Education · Tami Boatright Ed.D, Director, K-8 Education · Andrea Valadez, Administrator, Special Education & Support Services
CALIFORNIA IMMUNIZATION REQUIREMENTS FOR PRESCHOOL ENROLLMENT
Your child must have the immunizations listed below to attend Preschool A copy of your child’s Immunization Record must be provided along with your application as proof of immunization If your child has not received the Tuberculosis Skin Test (PPD), then a current California Tuberculosis Risk Assessment dated after the last birthdate must be submitted along with the immunizations
Vaccines
Required Dose(s) To Attend Preschool
Polio
3 doses – After age 4…if last one given before 2nd birthday, will need the 4th dose
DTP/DPaP/DT/Td
4 doses – After age 4…if last one given before 2nd birthday, will need the 5th dose
MMR (Measles, Mumps, Rubella)
1 dose – Must be given on or after the 1st birthday - **After age 4, will need 2nd dose 1 dose – Last dose must be given on or after the 1st birthday – If no dose given, one dose required until 4 ½ yrs. old
Hib Meningitis
3 doses (3 dose series)
Hepatitis B
1 dose – Must be given on or after the 1st birthday or Health Care Provider must document if child has had chickenpox and shot will not be required
Varicella
Tuberculosis Skin Test (PPD)
1 dose – Must be given within one year of entry into school (after August 1st of last year & before August of this year
To obtain immunizations, contact your Authorized Health Care Provider, Local Health Clinics or The Fresno County Department of Community Health Immunization Clinic. If your child’s immunizations are not up-to-date, parents will need to make an appointment prior to the Registration.
If you do not have private insurance, you may contact:
Fresno County Department of Health 1221 Fulton Mall - First Floor Phone: 600-3550 Parent or legal guardian must be present Bring your child’s immunization card or shot record Bring Medi-Cal Card Immunizations will be given on a first-come, first served basis Walk Ins - Monday and Wednesday from 8:00 am to 11:00 am and 1:00 pm to 3:00 pm
If you do have private insurance, you may contact: Clinic Sierra Vista - Fresno locations: 457-5800 (Appointment Needed) United Health Clinics - Kerman: 846-6330 Valley Health Team - Kerman: 846-9359
Parent or legal guardian must be present Bring your child’s immunization card or shot record Bring Proof of Health Insurance Clinics provide Medical and Dental Care options
(Closed 12:00 to 1:00 for lunch)
FOR CALIFORNIA TUBERCULOSIS RISK ASSESSMENTS ONLY
You may call the School Nurse at any district school site to schedule an appointment Imm Req 3/17
Declaration Under Penalty of Perjury
(Declaration of Residency)
I _______________________________________am not responsible for the care and welfare Name of Owner of Home
for ______________________________________ and her/his child(ren) __________________ Name(s) of Preschooler’s Parent(s)
List Name(s) of Child(ren)
______________________________________________________________who live with me at _____________________________________________________________________________. Street Address
City
Zip Code
NOTE: Must bring current PG&E bill with the same name as listed above of owner of home and address with this form.
I declare under penalty of perjury that the above information is true and correct to the best of my knowledge. _________________________________
__________________________
Signature
Date
Declaración Bajo Pena de Perjurio (Declaración de Residencia)
Yo _______________________________________no soy responsable del cuidado y el Nombre de Propietario de la Casa
bienestar de ________________________________________________________ y los niño(s) Nombre(s) de los Padre(s) del Niño
______________________________________________________________que vive con migo Nombre(s) de los Niño(s)
en __________________________________________________________________________. Dirección de la Casa
Ciudad
Código Postal
NOTA: Debe traer cuenta de la luz (PG&E) con el mismo nombre como listó arriba de propietario de la casa y la dirección con esta forma
Declaro bajo pena de perjurio que la información anterior es verdadera y correcta a lo mejor de mi conocimiento. _________________________________
__________________________
Firma
Fecha Declaration Under Perjury 11/14
Received Date
2017-2018 STATE PRESCHOOL APPLICATION PRESCHOOL CHILD’S NAME ________________________________________ Birth Date________________ Is the preschool child fully toilet trained? Yes
Are there any special needs or concerns regarding your child? If so, please explain:
No
Enrolling Parent/Guardian__________________________________________________________
Mother
Father
Guardian
Foster Parent
Cell # ___________________________________ Work # ___________________________________ Home # ___________________________________ Email Address: ________________________________________________________________________________________________________________ Enrolling Parent/Guardian__________________________________________________________
Mother
Father
Guardian
Foster Parent
Cell # ___________________________________ Work # ___________________________________ Home # ___________________________________ Email Address: ________________________________________________________________________________________________________________ Parent Marital Status:
Married
Is Father In The Home?
Yes
Divorced No
Domestic Partnership
Single
Is Mother In The Home?
Yes
Separated
Common-Law
Widow/Widower
No
Who is responsible in providing the care & welfare for the preschooler? Mother
Foster Mother
Father
Foster Father
Boyfriend
Girlfriend
Guardian
Grandfather
4 Digit Code
Grandmother
Home Address: ______________________________________________________ City_________________ Zip Code_______________ Mailing Address/P.O. Box: _____________________________________________ City_________________ Zip Code_______________ FAMILY SIZE INFORMATION – List ALL CHILDREN residing in the home and counted in the family size Full Name of Child Including Middle Initial M/F Birth Date Full Name of Child Including Middle Initial
M/F
Birth Date
FAMILY INCOME INFORMATION What is Father/Guardian’s Gross Monthly Income $ ______________ Is Father/Guardian Employed? Yes No Do you get paid by check or cash? Check Cash How often do you get paid? Weekly
Bi-Weekly
2X’s Per Month
Monthly
What is Mother/Guardian’s Gross Monthly Income $ ______________ Is Mother/Guardian Employed? Yes No Do you get paid by check or cash? Check Cash How often do you get paid? Weekly
Bi-Weekly
2X’s Per Month
Monthly
Is Father/Guardian receiving Cash Aid? Yes No Amount of Monthly Cash Aid received: $______________
Is Mother/Guardian receiving Cash Aid? Yes No Amount of Monthly Cash Aid received: $______________
Does Father/Guardian receive additional monetary benefits/support? Yes No If yes, which type:________________________________ Amount of benefits/support received: $______________
Does Mother/Guardian receive additional monetary benefits/support? Yes No If yes, which type:________________________________ Amount of benefits/support received: $______________
If you have NO INCOME, please explain how you support your family on a monthly basis: ______________________________________________
If you have NO INCOME, please explain how you support your family on a monthly basis: ________________________________________________________
PRESCHOOL SITES BIOLA-PERSHING: CENTRAL DEMONSTRATION: HERNDON BARSTOW: MADISON: TEAGUE:
CLASS TIMES AM (8:30-11:30) or PM (12:30-3:30) AM (8:00-11:00) or PM (12:00-3:00) AM (8:45-11:45) or PM (12:45-3:45) AM (8:30-11:30) or PM (12:30-3:30) AM Not Available PM (12:45-3:45)
LIST PRESCHOOL SITE CHOICES
CIRCLE CLASS TIME PREFERENCE
#1 ______________________________
AM
PM
NO PREFERENCE
#2 ______________________________
AM
PM
NO PREFERENCE
#3 ______________________________
AM
PM
NO PREFERENCE
#4 ______________________________
AM
PM
NO PREFERENCE
