FREMONT UNION HIGH SCHOOL DISTRICT EMERGENCY & HEALTH INFORMATION
LYNBROOK HIGH SCHOOL
FINAL CLASS SCHEDULE WILL NOT BE ISSUED UNTIL THIS FORM IS COMPLETED AND SIGNED
2017‐18 SCHOOL YEAR
In order for your student(s) to begin school, you must complete/update all 6 parts of this form and submit it to your student’s high school. Notify the school office of any changes that occur during the school year! If you have questions or concerns, please contact the school.
PART I – STUDENT INFORMATION
Student’s Legal Last Name
Student’s Legal First Name
Student ID#
Grade
Gender
Birth Date (M/D/YYYY) Student E‐mail
Student Cell #
PART 2 – PARENT OR LEGAL GUARDIAN #1 (With Whom The Student Is Residing)
Legal Last Name
Legal First Name
Middle Name
Relationship
Gender
Birth Date (M/D/YYYY) Work Phone
Cell/Mobile Phone
Street Address of Home
Apt.
City
ZIP Code (9 digits if known)
Home Phone
E‐mail Address
Employer
PART 3 – PARENT OR LEGAL GUARDIAN #2
Legal Last Name
Legal First Name
Middle Name
Relationship
Gender
Birth Date (M/D/YYYY) Work Phone
Cell/Mobile Phone
Street Address of Home
Apt.
City
ZIP Code (9 digits if known)
Home Phone
E‐mail Address
Employer
Is either parent/guardian on active duty in the U.S. armed forces (Army, Navy, Air Force, Marine Corps or Coast Guard) or on full-time National Guard duty?
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PART 4 – EMERGENCY CONTACT INFORMATION
The individuals listed below have authorization to pick up my child and can be reached during the school hours at the numbers listed. Two Emergency Contacts who are at least 18 years old are required (other than parent). Legal Last Name Legal First Name Relationship to Student
Home or Work Phone
Gender
Cell/Mobile Phone
Legal Last Name
Legal First Name
Relationship to Student
Home or Work Phone
Gender
Cell/Mobile Phone
Legal Last Name
Legal First Name
Relationship to Student
Home or Work Phone
Gender
Cell/Mobile Phone
PART 5 – HEALTH INFORMATION In case of serious accident or illness at school, your child will be sent to an emergency medical facility. Parent(s) / guardian(s) will be responsible for all emergency medical expenses.
Physician’s Name
Physician’s Phone Number
Medical Record Number
Please mark the box if your student has or carries any of the following:
Seizure Disorder
Diabetes
Mild/Moderate Asthma
*Epipen for
allergy
Severe Asthma
*Carries Inhaler
Does NOT Carry Inhaler
*Permission form to carry/take medication at school must be on file in the office (CA Education Code #49423). You may Download the form from the District website at: http://www.fuhsd.org/meds .
Please list all current medications and the condition requiring the medication:
Medication #1
Condition/Purpose
Medication #2
Condition/Purpose
Please list/describe any other Diagnosed Health Problems:
Emergency Comments:
PART 6 – PARENT/LEGAL GUARDIAN SIGNATURE (signature of parent with whom the student resides)
Printed Name of Parent/Guardian
Signature of Parent/Guardian
Date
FREMONT UNION HIGH SCHOOL DISTRICT PARENT/STUDENT RIGHTS AND RESPONSIBILITIES
LYNBROOK HIGH SCHOOL
2017‐18 SCHOOL YEAR
ZERO TOLERANCE ‐ ACADEMIC HONESTY TECHNOLOGY USE & PHOTO/VIDEO RELEASE
In order for your student(s) to begin school, you must complete all parts (both pages) of this form and submit it to your student’s high school. If you have questions, please contact the school. Copies of all policies and agreements can be found on the District website: http://www.fuhsd.org/annual‐notifications.
Student’s Legal Last Name
Student ID # Grade
Student’s Legal First Name
School
LHS
ACKNOWLEDGMENT OF PARENT/STUDENT RIGHTS AND RESPONSIBILITIES – CA. ED. CODE# 48982
The FUHSD Annual Notification of Parent/Student Rights and Responsibilities is available on the District website at http://www.fuhsd.org/annual‐notifications. Hard copies are also available at your school. A letter notifying you about these rights and how to access the full annual notifications was mailed in August.
I acknowledge that I have been informed of my rights as a parent/legal guardian of an FUHSD student.
Printed Name of Parent/Guardian
Signature of Parent/Guardian
Date
ZERO TOLERANCE POLICY NOTIFICATION – CA. ED. CODE# 48915
Expulsion MUST be recommended for the following behaviors: (1) Possessing, selling, or otherwise furnishing a firearm. (2) Possession/brandishing of any knife; possession of an explosive, or other dangerous object of no reasonable use to the pupil. (3) Unlawful possession, sale or distribution of any controlled substance. (4) Causing serious physical injury to another person; robbery or extortion. (5) Assault or battery upon any school employee.
A list of behaviors for which the district MAY recommend expulsion, can be found in the Annual Notification of Parent/Student Rights and Responsibilities: http://www.fuhsd.org/annual‐notifications.
______________________and I have read the FUHSD’s Zero Tolerance notification and understand that the above offenses can lead to expulsion from the District.
Printed Name of Parent/Guardian
Signature of Parent/Guardian
Date
Academic Honesty Policy Agreement
_________________ and I have read and agree to abide by the FUHSD Academic Honesty Policy. I understand that violations can have serious academic consequences which may negatively impact college admissions and opportunities for scholarships.
Printed Name of Parent/Guardian
Signature of Parent/Guardian
Date
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ACCEPTABLE USE OF TECHNOLOGY AGREEMENT
_______________________ and I have read the FUHSD Student Technology Use Policy. I agree to follow the rules contained in this policy. I understand that if I violate the rules, I may face disciplinary action and/or legal sanction in addition to termination of access to school computers and my Internet account.
Printed Name of Parent/Guardian
Signature of Parent/Guardian
Date
Parent/Guardian
I have read the FUHSD Student Technology Use Policy. I hereby give permission for my child to use the Internet. I understand that this permission includes permission for my child to access information through the Web, receive an individual e‐mail account, engage in other educationally related electronic communication activities, and provide personal information to others for education or college/career exploration reasons or as approved by school staff.
I hereby release the District, its personnel, and any institutions with which it is affiliated from any and all claims and damages of any nature arising from my child’s use of, or inability to use, the District system, including but not limited to claims that may arise from the unauthorized use of the system to purchase products or services or exposure to potentially harmful or inappropriate material or people.
I understand that I can be held liable for damages caused by my child’s intentional misuse of the system. I will instruct my child regarding restrictions against accessing material and the consequences for misuse of the Internet system as set forth in the District policy. I will emphasize to my child the importance of following the rules for personal safety.
Printed Name of Parent/Guardian
Signature of Parent/Guardian
Date
PHOTO/VIDEO RECORDING RELEASE
Permission is requested for a student to be photographed or video‐recorded during the school year. These videos and photos may appear on printed material (i.e., yearbook, school newspaper, etc.), on the District or high schools’ Web sites, or as part of an assessment of student teachers. _________________________ and I _____________________________
Printed Name of Parent/Guardian
Signature of Parent/Guardian
Date
