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BUSD Enrollment Forms Grades: 4K, TK, K, and 1st
Please return to: Central Enrollment Center
551 South Avenue H
Barstow, CA 92311
760-255-8800 / Fax: 760-255-8801
Hours: 8:00 am – 2:00 pm, Monday-Friday
REQUIRED DOCUMENTS:
Official Birth Certificate or Passport Proof of Immunization (Shot Records – MUST be up to date) Report of Health Examination for School Entry (completed by physician) Mandated Oral Health Assessment (completed by dental professional) Proof of Residency (ie: mortgage statement, rental agreement, utility bill, DMV registration, other government issued mail)
The student listed below is enrolling in our district, please forward information requested to the site indicated below. DATE 1st Request 2nd Request 3rd Request
STUDENT NAME Grade Birthdate
Last School of Attendance Phone ______________________________ Address Fax
I, the undersigned hereby consent to, request, and authorize the above to release any and all information: Redisclosure: I understand that health information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and it is no longer protected by federal law and regulations regarding the privacy of protected health information. I further understand the confidentiality of the information when released to a public education agency is protected as a student record with the family Education Rights and Privacy Act (FERPA) and treated in accordance with Health Insurance Portability and Accountability Act (HIPAA) privacy regulations. I authorize the proceeding individual or organization to disclose the above named individual’s health/educational information for inclusion in their records which are to be used for offering services to said student.
Parent/Guardian Name Signature of Parent/ Guardian
Records Request Please fax immediately Please mail complete cumulative File
Please Send ALL Education Records Official Transcript Birth Certificate Attendance Record Discipline/Behavior Report Health Evaluation/Physical State Test Scores Psychological Report
Birth Certificate Immunization Record/or Waiver Last Report Card 504 Plan Special Ed Records/Current IEP/Speech/ (if applicable) Psychological ReportUnofficial Transcript Withdrawal GradesOther
Expulsion/Readmit Information Dental Evaluation ELD-English Learning Development Test Scores
COMMENTS: Other
Please forward the information to the attention of location checked below Staff (Name) Requesting:
PS October 2017
RELEASE OF RECORDS
☐ Barstow Fine Arts Academy 760-255-4901 FAX 760-255-4906☐ Cameron Elementary School 760-255-6260 FAX 760-255-6261☐ Crestline Elementary School 760-252-5121 FAX 760-252-5152☐ Henderson Elementary School 760-255-6250 FAX 760-255-6253☐ Lenwood Elementary School 760-253-7713 FAX 760-253-7708☐ Montara Elementary School 760-252-5150 FAX 760-252-5185
760-255-6090 FAX 760-255-6095760-255-6151 FAX 760-255-6104760-255-6202 FAX 760-255-6203
☐Skyline Elementary School☐Barstow STEM Academy☐Barstow Jr. High School☐Barstow High School 760-255-6119 FAX 760-255-6120☐ Central High School 760-255-6060 FAX 760-255-2125☐ Central Enrollment Center 760-255-8800 FAX 760-255-8801☐ OTHER FAX
Please mail records: BUSD-ATTN: (Please indicated School Site) 551 South Avenue H., Barstow, CA 92311
Barstow Unified School District - ENROLLMENT FORM For Office Use Only (Staff Initials Required)
Proof of Residency Immunization RecordsBirth Certificate Oral Health Assessment Report of Health Checkup TranscriptsTransfer In Packet IEP/Psych/504/Speech LegalMKV
BARSTOW UNIFIED SCHOOL DISTRICT 551 South Avenue H Barstow, CA 92311 Today’s Date
Date of Entry
Grade
Student ID#
STUDENT IDENTITY INFORMATION (Please Print Clearly) LEGAL NAME LAST NAME FIRST NAME MIDDLE Suffix FORMER/Nick Name LAST NAME FIRST NAME Middle GENDER Male Female DOB Grade Level BIRTHPLACE City State County
Has student ever attended school in Barstow Unified School District? Yes No If YES, School Gr
Student’s Ethnicity? (federally mandated information) Please check one Hispanic or Latino Not Hispanic or Latino
WHAT IS YOUR CHILD’S RACE? (federally mandated information) You may mark up to five racial categories: The above question is about ethnicity, not race. No matter what you selected above, please continue to answer the following by marking one or more boxes to indicate what you consider the student’s race to be.
American Indian or Alaskan Native (100) Laotian (206) Samoan (303) Chinese (201) Cambodian (207) Tahitian (304) Japanese (202) Hmong (208) Other Pacific Islander (399) Korean (203) Other Asian (299) Filipino/Filipino American (400) Vietnamese (204) Hawaiian (301) African American or Black (600) Asian Indian (205) Guamanian (302) White (700)
HOME LANGUAGE SURVEY (If your child has attended BUSD schools before coming to this school SKIP to the next section. You only complete this one time for the DISTRICT. Which language did the student learn when he/she first began to talk? What language does the student most frequently use at home? What language do you use most frequently to speak to your student? What language is most spoken by the adults at home? Has the student ever been enrolled in a US school for 3 or more full Years? Yes No
PARENT EDUCATION- Check the response that describes the education level of the most educated parent. (federally mandated information)
Graduate Degree or Higher College Graduate Some College or Associate’s Degree High School Graduate Not a High School Graduate
PARENT/GUARDIAN INFORMATION (with whom the student lives) Check all that apply Father Mother Both Step-Father Step-Mother Guardian Foster/Group Home Other
Is the above (checked) person(s) the student’s LEGAL guardian? Yes No If NO, please complete a “Caregiver Affidavit” IF YES, and there is a legal custody agreement regarding this student, please check type: Joint Custody Sole Custody Guardian Copies of legal agreement paperwork Yes No, IF No: inform parent/guardian we cannot enforce, if we have no legal documentation.
SCHOOL _________________________
Has your child ever been expelled? Yes No If Yes, Date School
What special services has your child received? Please check all boxes that apply and supply most recent IEP/504
Individualized Education Plan (IEP)Speech / Language504 PlanEnglish Language DevelopmentOther (Specify) _____________________________________
Date Student first attended school in the United States? ______________________________________________
Month Day Year
Date Student first attended school in California? _________________________________________
Month Day Year
Signature of Parent/Legal Guardian Relationship to Student Date
REV. CEC 021920
BARSTOW BARSTOW UNIFIED SCHOOL DISTRICT
551 South Avenue “H”, Barstow, CA 92311 (760)255-6026 Date: _________
☐ Street Address is a hotel, shelter, or transitional residence ☐ Unaccompanied Youth
☐ We are living with another family due to financial hardship ☐ Foster Youth (if checked, please complete
Foster Youth Intake Form) ☐ We are living in a car or campsite because of financial hardship
STOP: If you checked any of the above boxes, please skip section B and fill out section C
NOTE: If you checked any of the boxes above, you WILL BE contacted by our District Outreach Liaison for additional services
☐ Sharing housing NOT due to a financial reason
☐ Street address is a hotel/motel-awaiting permanent housing ☐ Home owner or permanent housing
Section B - PARENT/LEGAL GUARDIAN/CAREGIVER (only one required to complete this section):
DOCUMENTATION PROVIDED FOR REGISTRATION:
☐ Current utility bill (electric/gas/water/trash ONLY) in the primary residence/homeowner/landlord’s name; OR
☐ One of the following items in your name with street address shown above: DMV Vehicle Registration; current bank
Statement; current payroll stub; property tax payment receipt; rental property contract, lease or payment receipts;
utility service contract, statement; pay stubs; voter registration; or correspondence from a Government agency; OR
☐ Declaration of Residency executed by parent/guardian/caregiver
I,_____________________________________________________, declare that:
I am the parent/legal guardian/caregiver of the above named student; AND ____________ (initial)
We reside at the street address shown above; AND ________ (initial)
I understand under California Education code 48200 that all students are legally bound to attend schools in their
district of primary residence; AND _______ (initial)
I do not have a current utility bill in my name for the above street address; AND _________________ (initial)
The information included in this affidavit is true and correct to the best of my knowledge. _________ (initial)
Section C - Please read the following statements and initial:
Barstow Unified School District may actively investigate all cases where it has reason to believe false information has
been provided. ________(initial)
Investigation that reveal students have enrolled on the basis of providing false information may lead to withdrawal from
the school. _____ (initial)
I certify under Penalty of Perjury under the laws of the State of California that the foregoing is true and correct.
________________________________________ ______________________
Signature of Parent/Legal Guardian/Caregiver Date
STUDENT RESIDENCY QUESTIONNAIRE/STATEMENT OF RESIDENCE AFFIDAVIT
School of Residence (check one):
☐ Cameron ☐ Crestline ☐ Henderson ☐ Lenwood
☐ Montara ☐ Skyline ☐ Barstow STEM ☐ Barstow Junior High
☐ Barstow High School ☐ Central High School ☐ Other: (Please specify) ____________________
Section A
Student Name: ____________________________________________________________ DOB_____/_____/_______
Street Address, City & Zip Code:
_______________________________________________________________________________________________
Name of Parent(s)/Legal Guardian(s)/Caregiver(s):
____________________________________________________________________Phone #:_____________________
PS Updated March 2015 Page 1 of 1
Barstow Unified School District Student Health Information
Student Name: __________________________________________________Grade _______ Birthdate_________________ Last First Initial Home Phone _______________________ Work Phone_________________________ Cell Phone _____________________ PARENT/GUARDIAN: Please check the appropriate box(es), if any, that best describes your student’s current health condition(s) and return the completed form to school. Please provide specific information regarding conditions that may affect student learning and participation in school activities. MEDICATION: All medication (prescription, over-the-counter, homeopathic remedies, vitamins, etc.), which is to be administered during the school day, or during school-sponsored activities, requires an Authorization for Medication Administration to be completed and signed by physician and parent. Students are not allowed to carry medication and/or inhalers without a signature by physician and parent on Authorization for Medication Administration form. √ Health Condition Medication Specific Information
ADD/ADHD Allergy-Bee/Insect Life Threatening Yes No Allergy-Food Life Threatening Yes No Allergy-Medication Life Threatening Yes No
Allergy-Other(animal,latex,etc.) Life Threatening Yes No
Asthma- Mild Moderate Serious Autism Birth Defect/Genetic Disorder Bladder/Kidney Problem Blood disorders (Chronic) Cerebral Palsy Colitis/Crohn’s Disease Confidential Health Problem (call District Nurse) Diabetes(Requires meeting w/District Nurse) Down Syndrome/Intellectual Disability Emotional/Psychological/Eating Disorder Hearing Problems (infections, tubes, nerve damage, etc.) Deaf/Hard of Hearing Right Ear Left Ear Hearing Aids Right Ear Left Ear Heart Problems– No restrictions or Restrictions Hemophilia – Call District Nurse Hypoglycemia/physician diagnosed Medication Taken at Home, explain Medication Taken at School (Requires physician note) Menstrual Problems (Severe) Migraine Headaches (physician diagnosed, list med) Nosebleeds – Severe Orthopedic Condition-Description: Physical Activity Limitation (Requires physician note) Prosthesis Scoliosis (physician diagnosed) Seizure Disorder-Type: Sickle Cell Anemia (explain) Skin Disorder Speech Difficulties Traumatic Brain Injury
Tuberculosis/or history of positive skin tests Chest X-ray required w/positive skin test. List Med
Visual Impairment Right Eye Left Eye Glasses/Contact lens Distance Reading
Other Health Concern(s) not listed-Describe:
NO HEALTH CONCERNS AT THIS TIME Do you currently have Health Insurance/Medi-cal? Yes No Dental Insurance Yes No Vision Insurance Yes No If yes, please state name of insurance company or companies: ______________________________________________________________ IF IN NEED OF EMERGENCY MEDICAL CARE AND WE ARE NOT ABLE TO CONTACT YOU, WE WILL CALL 911. STUDENTS MAY BE TRANSPORTED TO Barstow Community Hospital. _______________________________________________ ______________________________________ Parent/Guardian Signature Date
PS 2015
Page 1 of 2 ‐ PS January 2018
BARSTOW UNIFIED SCHOOL DISTRICT
PARENT NOTIFICATION OF STATE IMMUNIZATION REQUIREMENTS
Immunizations – EC 49403 and 48216, HSC 120335, 120365, and 120370 ‐ Students must be immunized
against certain communicable diseases. Students are prohibited from attending school unless
immunization requirements are met for age and grade. The school district shall cooperate with local
health officials in measures necessary for the prevention and control of communicable diseases in school
age children. The district may use any funds property of personnel and may permit any person licensed
as a physician or registered nurse to administer an immunizing agent to any student whose parents have
consented in writing.
Beginning January 1, 2016 parents of students in any school, will no longer be allowed to submit a
personal beliefs exemption to a currently required vaccine. A personal beliefs exemption on file at school
prior to January 1, 2016 will continue to be valid until the student enters the next grade span at
kindergarten (including transitional kindergarten) or 7th grade.
Students are not required to have immunizations if they attend a home‐based private school or an
independent study program and do not receive classroom‐based instruction. However, parents must
continue to provide immunization records for these students to their schools. The immunization
requirements do not prohibit students from accessing special education and related services required by
their individualized education programs.
A student not fully immunized may be temporarily excluded from a school or other institution when that
child has been exposed to a specified disease and whose documentary proof of immunization status does
not show proof of immunization against one of the communicable diseases described above. State law
requires the following immunizations before a child may attend school:
a. All new students, in transitional kindergarten through grade 12, to the Barstow Unified School District
must provide proof of polio, diphtheria, pertussis, tetanus, measles, mumps, rubella, and varicella
immunizations.
b. All transitional kindergarten and kindergarten students must also provide proof of vaccination against
hepatitis B.
c. All seventh grade students must also provide proof of a second immunization for measles, mumps,
rubella, and a pertussis booster vaccination. Free‐or low‐cost immunizations for children are available at
Public Health. Please call 1‐800‐722‐4777 for information. Information about a medical exemption or
personal beliefs exemption from immunizations for your student is available at 1‐800‐722‐4777.
Inmunizaciones – CE 49403 y 48216, HSC 120335, 120365, y 120370 ‐ Los estudiantes deben ser
inmunizados contra ciertas enfermedades contagiosas. Está prohibido a los estudiantes asistir a la escuela
a menos que se cumplan los requisitos de las inmunizaciones para la edad y el grado del estudiante. El
distrito escolar deberá cooperar con las autoridades de salud locales en las medidas necesarias para la
prevención y control de enfermedades contagiosas en ninos de edad escolar. El distrito podría usar
cualquier fondo, propiedad, o personal y puede permitir a cualquier persona autorizada como médico o
enfermera titulada a administrar un agente de inmunización a cualquier estudiante que los padres hayan
consentido por escrito. Empezando el 1 de enero de 2016, a los padres de los estudiantes en cualquier
escuela no se les permitirá presentar una exención a una vacuna actualmente exigida. Una creencia
Page 2 of 2 ‐ PS January 2018
personal en el archivo escolar fechada antes del 1 de enero de 2016 continuará siendo válida hasta que
el estudiante entre al siguiente periodo de grados en kindergarten (incluyendo kindergarten de transición)
o 7º grado.
Los estudiantes no están obligados a tener las vacunas si asisten a una escuela privada en el hogar, o un
programa de estudios independiente y no reciben instrucción en el aula. Sin embargo, los padres deben
seguir proporcionando registros de inmunizaciones para estos estudiantes a sus escuelas. Los requisitos
de inmunización no prohíbe a los estudiantes el acceso a la educación especial y servicios relacionados
por sus programas educativos individualizados.
Un estudiante que no tenga todas las vacunas puede ser excluido temporalmente de una escuela u otra
institución cuando el niño/a haya sido expuesto a una enfermedad específica y que la documentación de
prueba de inmunización no muestre una prueba de inmunización contra una de los enfermedades
contagiosas anteriormente descritas.
La Ley estatal requiere las siguientes inmunizaciones antes de que un niño pueda asistir a la escuela:
a.Todos los nuevos estudiantes, de kínder transicional al grado 12, en el Distrito Escolar de Barstow deben
proveer prueba de las inmunizaciones contra la poliomielitis, difteria, tos ferina, tétanos, sarampión,
paperas, rubéola y varicela.
b.Todos los estudiantes en el kínder transicional o kínder también deben proveer prueba de las vacunas
contra la hepatitis B.
c.Todos los estudiantes en el séptimo grado también deben proveer prueba de la segunda inmunización,
paperas, rubéola y una dosis de refuerzo para la inmunización contra la tos ferina. Se pueden conseguir
inmunizaciones gratuitas o económicas para los niños en el departamento de Salud Pública. Por favor
llame al 1‐800‐722‐4777 para más información. Información sobre exención de inmunización por motivos
médicos o religiosos para su estudiante está disponible 1‐800‐722‐4777.
CEC 021920
Barstow Unified School District Student EMERGENCY Form
Please fill out completely and sign where indicated. In an emergency it is the school district policy to retain students at school for their safety. This form will be used by the school staff when student(s) are released to go home during a school emergency.
STUDENT’S LAST NAME FIRST NAME Middle Name
Birthdate Male Female Grade Home Language
Student Address Apt # City State/Zip
MAILING ADDRESS -if Different Apt # City State/Zip
To the Principal: In case you are unable to reach me during any emergency, you are authorized to contact and, if necessary, release my child to any of the following:
Name: ______________________________________________________ Relationship: ___________________________ DOB ______________ Phone Numbers Home # __________________________ Cell # ________________________ Work # ________________________
Name: ______________________________________________________ Relationship: ___________________________ DOB ______________ Phone Numbers Home # __________________________ Cell # ________________________ Work #: ________________________
Name: ______________________________________________________ Relationship: ___________________________ DOB ______________ Phone Numbers Home # __________________________ Cell # ________________________ Work # ________________________
Please complete both sides of the BUSD Student Emergency Form Page 1 of 2
OFF
ICE
USE
O
NLY
STUDENT # Teacher
ALERTS Medical
Legal Household Name
HOUSEHOLD 1-Whom Student Lives With
Parent's/Legal Guardian's Last Name ____________________________________ First Name ____________________________________Relationship to Student: ____________________________________ Lives With Yes No DOB ______________________Home Address ____________________________________________________ City/State/Zip: __________________________________Work Address ____________________________________________________ City/State/Zip: __________________________________ Phone Numbers Home # __________________________ Cell # ________________________ Work # ________________________
Email Address ____________________________________ Legal Guardian Yes No Active Military Yes No Branch: ________________________
HOUSEHOLD 2
Parent's/Legal Guardian's Last Name ____________________________________ First Name ____________________________________Relationship to Student: ____________________________________ Lives With Yes No DOB ______________________Work Address ____________________________________________________ City/State/Zip: __________________________________
Phone Numbers Home # __________________________ Cell # ________________________ Work # ________________________ Email Address ____________________________________ Legal Guardian Yes No Active Military Yes No
Branch: ________________________
Parent's/Legal Guardian's Last Name ____________________________________ First Name ____________________________________Relationship to Student: ____________________________________ Lives With Yes No DOB ______________________Work Address ____________________________________________________ City/State/Zip: __________________________________
Phone Numbers Home # __________________________ Cell # ________________________ Work # ________________________ Email Address ____________________________________ Legal Guardian Yes No Active Military Yes No
Branch: ________________________
Additional Mailing Request Yes No
EMERGENCY MEDICAL TREATMENT
(Education Code 49407) In the event your child is ill or injured during regular school hours and such illness or injury required medical treatment such as but not limited to an x-ray, examination, medical or surgical diagnosis/treatment and/or hospital care as advised by any licensed physician, to be rendered the parent or guardian cannot be reached the school district, school principal, physician or hospital treating child shall not be held liable for the reasonable treatment. Unless the parent or guardian has previously filed with the school district a written objection to any medical treatment other than first aid.
HEALTH ALERTS—List any medical condition which restricts physical activity or requires special attention. Include conditions such as asthma and allergies such as peanut and bee stings. If none, please indicate “none”.
Does the STUDENT HAVE HEALTH INSURANCE? (Check one) Yes No if YES Private Health Insurance Medi-Cal Other Medical Health Care ID Number Private Health Insurance Name roup # Name of Doctor/Medical Office Phone # of Doctor Office/Medical Office *If the student does not have health insurance, information on free or low-cost health care programs was provide at enrollment
Yes No
My child is allergic to the following medications My child currently takes the following medications:
I certify that I have read and understood this form and do hereby give my authorization for emergency medical treatment, and that all of the information I have provided on this form is true and correct.
Date Signature (Check one) Parent Legal Guardian
SIBLINGS: Full name of Brothers and Sisters (oldest first) living in this household (Please include all children)1. Name ____________________________________ DOB __________________ Grade __________ Relationship _________________________2. Name ____________________________________ DOB __________________ Grade __________ Relationship _________________________3. Name ____________________________________ DOB __________________ Grade __________ Relationship _________________________4. Name ____________________________________ DOB __________________ Grade __________ Relationship _________________________5. Name ____________________________________ DOB __________________ Grade __________ Relationship _________________________6. Name ____________________________________ DOB __________________ Grade __________ Relationship _________________________7. Name ____________________________________ DOB __________________ Grade __________ Relationship _________________________8. Name ____________________________________ DOB __________________ Grade __________ Relationship _________________________
CEC 021920
Please complete both sides of the BUSD Student Emergency Form Page 2 of 2
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Oral Health Assessment Form T07-003, English, Arial Font Page 1 of 1
Oral Health Assessment Form
California law (Education Code Section 49452.8) states your child must have a dental check-up by May 31 of his/her first year in public school. A California 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: □ Male □ Female
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 (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 31 of your child’s first school year. Original to be kept in child’s school record. PS June 2017
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.
Dear Parent/Guardian,
Barstow Unified School District CONFIDENTIAL FAMILY SURVEY 2019/2020
PLEASE COMPLETE THIS FORM
We need your help. The information you provide is confidential. It is used for the purpose of allocating state funds to support student learning at your child’s school.
PART I: Student information
Student Name Date of Birth
School Site Student Grade
PART II: Fill in the following information for Household Size and Household Income
1. Total number of adults and children living in your household. (Please mark only one bubble)
2. Total Annual Household income: (Please mark only one bubble)
Between $0‐$22,311 2 Between $22,312‐$30,044 3 Between $30,045‐$37,777 4 Between $37,778‐$45,510 5 Between $45,511‐$53,243 6 Between $53,244‐$60,976 7 Between $60,977‐$68,709 8 Between $68,710‐ $76,442 9 Between $76,443‐$84,175 10 Between $84,176‐$91,909 11+ More than $91,909
Add other BUSD School Age Children living in your home BUSD Student ID
(if Known) STUDENT NAME
Last Name, First Name Date of
Birth SCHOOL GR RELATIONSHIP TO STUDENT
ABOVE
PART III: Parent or Guardian Information and Signature
I certify (promise) that the information provided on this form is true and that I included all income. I understand that the school may receive state and federal funds based on the information it provided and the information could be subject to review.
Parent or Guardian Printed Name Parent or Guardian Signature Date
PS July 2018
