Odyssey Academy Beverly Hills
New Student Enrollment Packet Check List
2015-16
All NEW AEA students must submit the following completed forms:
___ Enrollment Information
___ Special Services Questionnaire
___ Request for Student Records
___ Emergency Contact Form
___ Health Information Form
___ Photo/Videotape Release
___ Community Service Agreement
___ Medication Authorization Form (if applicable)
Additional items to be submitted with completed Enrollment Packet:
___ Copy of Student Birth Certificate
___ Proof of Residency (copy of property tax statement or copies of 2 different utility bills)
Additional Forms for KINDERGARTEN & 1st GRADE students only:
___ Health Examination - to be completed by physician
___ Updated Immunization Records
___ Oral Health Assessment - to be completed by dentist
PLEASE MAIL COMPLETED ENROLLMENT PACKET TO:
Albert Einstein Academy
Attention: Odyssey Academy BH Admissions
25443 Orchard Village Road
Valencia, CA 91355
ODYSSEY ACADEMY BEVERLY HILLS
ENROLLMENT INFORMATION: SCHOOL YEAR 2015-2016
STUDENT INFORMATION
LEGAL NAME (LAST, FIRST, MIDDLE)
GENDER (MALE/FEMALE)
STREET ADDRESS
CITY
ZIP CODE
HOME PHONE NUMBER + AREA CODE
E-MAIL ADDRESS FOR ALL
ENTERING WHAT GRADE (Fall 2015)
CORRESPONDENCE
Circle: K 1
STUDENT LIVES WITH:  MOTHER
2
3
4
5
DATE OF BIRTH (MM/DD/YY)
 FATHER  BOTH  OTHER
In a Single Family Permanent Residence
Doubled up
PLACE OF BIRTH
(house, apt, condo, mobile home )
(sharing housing with another
(CITY, STATE, COUNTRY)
In a shelter or transitional housing program
family)
In a motel/hotel
In a foster home
In a Licensed Child Institution
Unsheltered (car/campsite)
Other (Please specify)
PREVIOUS SCHOOL &
NAME/GRADE OF SIBLINGS
NAME/GRADE OF
DISTRICT OF RESIDENCE (2014-2015)
ATTENDING AEA SCHOOLS
SIBLINGS ON WAIT LIST
DATE FIRST ENTERED IN A U.S. SCHOOL:
/
/
DATE FIRST ENTERED IN A CA SCHOOL:
/
/
PARENT / LEGAL GUARDIAN (1)
NAME (LAST, FIRST, MIDDLE)
RELATIONSHIP TO STUDENT
STREET ADDRESS
CITY
ZIP CODE
HOME PHONE NUMBER + AREA CODE
WORK PHONE NUMBER + AREA CODE
CELL PHONE + AREA CODE
EMAIL ADDRESS
Highest Education Level Completed
Not a high school graduate
High School Graduate
Some college
College Graduate
Graduate School/Post Grad
Decline to State
PARENT/ LEGAL GUARDIAN (2)
NAME (LAST, FIRST, MIDDLE)
RELATIONSHIP TO STUDENT
STREET ADDRESS
CITY
ZIP CODE
HOME PHONE NUMBER + AREA CODE
WORK PHONE NUMBER + AREA CODE
CELL PHONE + AREA CODE
EMAIL ADDRESS
Highest Education Level Completed
Not a high school graduate
High School Graduate
Some college
College Graduate
Graduate School/Post Grad
Decline to State
INFORMATION FOR STATISTICAL USE ONLY
Is this student Hispanic or Latino? No, not Hispanic or Latino Yes, Hispanic or Latino
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 Ind./Alaskan Native
Asian Indian
Black or
Guamanian
Hawaiian
African American Japanese
Other Asian
Other Pacific Islander Hmong
Cambodian Chinese
Tahitian
Filipino
Korean
Laotian
Vietnamese
White/Caucasian
Samoan
HOME LANGUAGE SURVEY (Choose language from list below)
*What language did this student learn when he or she first began to talk?__________________________
*What language does your child most frequently use at home?___________________________________
*Name the language most often spoken by the adults at home.____________________________________
*What language do you use most frequently to speak to your child?_______________________________
*If other than English, your child will be individually assessed for English Language Proficiency
Albanian
Arabic
Armenian
Amer. Sign Lang.
Assyrian
Bengali
Burmese
Cantonese
Cebuano
Chaldean
Chamorro
Chaozhou
Dutch
Farsi
Filipino
French
(Guamanian)
(Chiuchow)
(Visayan)
(Tagalog)
German
Greek
Gujarati
Hebrew
Hindi
Hmong
Hungarian
Ilocano
Indonesian
Italian
Japanese
Khmer
Khmu
Kurdish
Korean
Lanu
(Cambodian)
Lao
Mandarin
(Kurdi, Kurmanji)
Marshallese
Mien (Yao)
Mixteco
Pashto
Polish
Portuguese
(Putonghua)
Pujabi
Rumanian
Russian
Samoan
Serbo-Croatian
Somali
Spanish
Taiwanese
Thai
Tigrinya
Toishanese
Tongan
Turkish
Ukranian
Urdu
Vietnamese
THE ACADEMY WILL BE NON-SECTARIAN IN ITS ADMISSIONS, PROGRAMS, POLICIES, EMPLOYMENT PRACTICES, AND ALL OTHER OPERATIONS, SHALL NOT
CHARGE TUITION, AND SHALL NOT DISCRIMINATE AGAINST ANY STUDENT OR STAFF MEMBER ON THE BASIS OF RACE, ETHNICITY, NATIONAL ORIGIN, OR DISABILITY.
PARENT / GUARDIAN SIGNATURE
I/WE HAVE REVIEWED THE INFORMATION AND TO THE BEST OF MY/OUR KNOWLEDGE, THE INFORMATION
THAT HAS BEEN PROVIDED IS TRUE AND COMPLETE. I UNDERSTAND THAT GIVING FALSE
OR INCOMPLETE INFORMATION REQUESTED HEREIN WILL RISK OR DELAY IN THE PROCESSING OF THE ABOVE-NAMED
STUDENT'S ENROLLMENT AND MAY JEOPARDIZE ENROLLMENT AT ANYTIME AT THE ALBERT EINSTEIN ACADEMY.
NAME OF PARENT / GUARDIAN (PRINTED):
RELATIONSHIP TO STUDENT:
SIGNATURE OF PARENT / GUARDIAN:
DATE
Odyssey Academy Beverly Hills
Special Services Questionnaire
In order to provide continuity in the educational environment, it is important that the school be
informed of any Special Education or 504 services received by your child in the past year.
A. Student’s Name: ___________________________ Grade in Fall 2015: __________
B. Does your child receive any educational services or assistance and/or has your child been diagnosed
with a learning disability?
(Complete Sections C & D)
D only)
C. If yes, please explain.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Please list any medications prescribed for your child relating to his/her current special needs.
_______________________________________________________________________
What type of Special Education services or testing has your child received?
_______________________________________________________________________
How long have these services been provided?________________________________________
***If your child has a current IEP (Individual Education Plan) or a 504 Plan, please list
the name of the district, the district contact, and their phone number. Please also attach
a copy of the IEP or 504 Plan.***
District Name: ____________________________________
District Contact: _____________________________ Phone:___________ Ext. #________
Please provide us with any additional comments/information that will help us support your child.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
D.
_______________________________________________________________________
Signature Of Parent Or Legal Guardian
Date
Preferred Phone Number
_______________________________________________________________________
Please Print Name Of Above Signer
Relationship To Student
Odyssey Academy Beverly Hills
Request for Student Records
Parent/Guardian: Please complete and sign.
Student Name:
Current Grade:
________________________________ __________________________ ___________________
Last Name
First Name
Middle Name
_____________
Date of Birth: _______________________
Current School: __________________________________________________
School Address: __________________________________________________
I hereby authorize the school listed above to release school records on file for the above named student
to Albert Einstein Academy Odyssey Academy Beverly Hills. I understand that my student will be
withdrawn from their current school.
Parent/Guardian: ____________________________
Relationship___________________________
(Print Name)
Parent/Guardian: ___________________________________
Date________________________
(Signature)
To the Current School: The student above is registering at AEA Odyssey Academy Beverly Hills. To
aid our enrollment process, please send us the following information for the student:
●
●
●
●
●
●
●
All report cards/progress reports
Results of all standardized tests and evaluations
Results of all cognitive abilities tests and evaluations
Results of all criterion-referenced tests and evaluations
Current health card
All Student Study Team (SST) evaluations and recommendations
All Special Education Records, including evaluations and IEP materials.
Please send this information (including this form) to the address listed below. Kindly
contact Admissions at [email protected] with any questions. Thank you.
AEA Odyssey Academy Beverly Hills
Attention: Admissions
8844 Burton Way
Beverly Hills, CA 90211
Odyssey Academy Beverly Hills
Emergency Contact & Medical Authorization
__________________________________________________________________________________
Student’s Last Name
First Name
Grade in 2015-16
__________________________________________________________________________________
Student’s Home Address (Street) (City) (Zip)
__________________________________________________________________________________
Student’s Home Phone
Student’s Birthdate
__________________________________________________________________________________
Parent/Guardian 1 Name
Relationship (Mother, Father, etc...)
Daytime Phone
__________________________________________________________________________________
Parent/Guardian 2 Name
Relationship (Mother, Father, etc...)
Daytime Phone
Please List Three Emergency Contacts:
__________________________________________________________________________________
Emergency Contact Name
Relationship To Student
Daytime Phone
__________________________________________________________________________________
Emergency Contact Name
Relationship To Student
Daytime Phone
__________________________________________________________________________________
Emergency Contact Name
Relationship To Student
Daytime Phone
I hereby GIVE consent for the following medical care providers and hospitals to be called:
__________________________________________________________________________________
Physician’s Name
Phone
Dentist’s Name
Phone
__________________________________________________________________________________
Medical Specialist’s Name
Specialty
Phone
History Please list any important facts about the child’s medical history that may require special attention by school personnel,
including allergies, medications being taken, and any physical impairment to which a physician should be alerted.
_______________________________________________________________________________________
In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any
treatment deemed necessary by above named doctors, or, in the event the designated preferred practitioner is not available, by
another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible. This authorization does
NOT cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for
such surgery, are obtained prior to the performance of such surgery.
__________________________________________________________________________________
Parent/Guardian Name (printed)
Signature of Parent/Guardian
Date
Health Information Form 2015-2016
Student’s Name___________________________________________________________________________________________________________
Last
First
Middle
Student’s date of birth ____/____/_______
Gender_________ State and Country of Birth_________________________________________
Student’s address___________________________________________City____________________State_____________Zip___________________
Name of Legal Guardian #1___________________________________Phone______________________Work/Cell___________________________
Email Address______________________________________________
Name of Legal Guardian #2___________________________________Phone_______________________Work/Cell__________________________
Email Address_____________________________________________
Emergency Contact_________________________________________ Phone______________________ Work/Cell_________________________
Email Address_____________________________________________
Pediatrician/Primary Care Doctor______________________________ Phone_______________________ Date of last appointment______________
Specialist_________________________________________________ Phone_______________________ Date of last appointment______________
Dentist__________________________________________________ Phone_______________________ Date of last appointment______________
Condition
Yes
Comment
Condition
Allergies
*Please indicate mild, moderate, or severe in
the comments section
Diabetes
Asthma or breathing problems
*Please indicate mild, moderate, or severe in
the comments section
Head Injury; concussion
Attention-Deficit/Hyperactivity Disorder
Hearing problems or deafness
Behavioral problems
Heart problems
Cancer
Muscle problems
Developmental problems
Seizures
Bladder problems
Sickle Cell Disease
Bleeding problems
Speech problems
Bowel problems
Spinal Injury
Cerebral Palsy
Surgery
Cystic Fibrosis
Vision problems
Dental problems
Other
Yes
Comment
Describe any other health-related information about your child (for example, feeding tube, hospitalizations, hearing aids, assistive devices, braces)
________________________________________________________________________________________________________________________
List all prescription, over-the-counter, and herbal medications your child takes regularly_________________________________________________
Is medication required during school hours? ⏩ Yes ⏩ No If Yes, medication name and reason for taking
________________________________________________________________________________________________________________________
Check here if you want to discuss confidential health information with the school nurse or other school authority ⏩ Yes ⏩ No
⏩ Yes ⏩ No Consent to contact doctor: The school nurse has permission to contact my child’s doctor if medically necessary.
I understand that the school needs to be informed of any health or medical conditions that may affect my child’s school day or impact their learning.
I also understand that the school nurse may need to share information about my child’s condition with appropriate school staff. If I do not wish that
information shared I must request this in writing and file it with the school nurse.
________________________________________________________________________________________________________________________
Parent/Guardian Signature
Parent/Guardian Name (printed)
Date
Odyssey Academy Beverly Hills
Photo/Videotape Release
2015- 2016
Throughout the school year, there may be times when the Albert Einstein Academy staff, the
media, or other organizations, with the approval of the school principal, may take photographs
of students, audiotape/videotape students, or interview students for school-related stories in a
way that would individually identify a specific student. Those photographs and/or
audio/videotaped images or interviews may appear in school or district publications; in school
or district video productions; on the school or district website; in the news media; or in other
nonprofit, education-related organizations’ publications.
I hereby grant Albert Einstein Academy permission to use my child’s photograph and/or
videotaped image for the purposes mentioned above. I understand and agree that Albert
Einstein Academy may use these photos and/or videotaped images in subsequent school years
unless I revoke this authorization by notifying the school principal in writing. I further grant
Albert Einstein Academy permission to allow my child to be photographed, audio/videotaped,
or interviewed by the news media or other organizations for school-related stories or articles.
Please check one:
▢
Yes, permission granted
▢
No, permission is not granted
Student’s Name __________________________Student’s Grade (2015-16)____________
Parent/Guardian’s Signature__________________________________________________
Odyssey Academy Beverly Hills
Community Service Requirements
COMMUNITY SERVICE PROGRAM
For each year enrolled at AEA Odyssey Academy, students must complete a minimum of 10 hours of
community service. Working together, students learn to solve problems, make decisions, and successfully
contribute to their community. They connect local concerns with global issues and gain an awareness of
others. All this will serve them now and years later as they transition out of school and into the adult
world.
Community Service Program Purpose:
● Help students become more active members of their community
● Increase student knowledge and understanding of their community
● Meet real community needs
● Foster relationships between the school and surrounding communities
● Encourage student altruism and caring for others
● Improve student personal and social development
● Teach critical thinking and problem solving skills
● Increase career awareness and exposure among students
● Improve student participation in attitudes toward school
● Improve student achievement in core academic courses
● Reduce student involvement in risk behaviors
● Global awareness
Community Service Guidelines:
Throughout the year, opportunities to perform community service will identified and made available. A
pre-approved list of organizations where students can volunteer is available on the school's website.
Students can also identify their own community service organizations and receive credit, with prior
approval. Examples of community service are: participating in charity walks, community beautification,
assisting at a food pantry or homeless shelter, collecting needed items for local charities, forming a litter
patrol or recycling program on campus, visiting senior living facilities and making centerpieces, holiday
cards or placemats. Classrooms may also create community service projects, but it is up to the student to
seek out opportunities and complete their hours. Community Service Forms must be turned in with an
authorized signature and Student Reflection to receive credit.
Community Service Activity Forms, Prior Approval Forms and procedures for submitting hours can be
downloaded from the school's website. Please keep a copy for your records. Forms not filled out
completely will not be accepted. An authorized signature from a supervisor on duty is required.
I have read the above information and agree to the requirements.
__________________________________
Parent/Guardian Signature
____________________________
Date
MEDICATION AUTHORIZATION FORM
Dear Parent/Guardian,
If a student must take medication he/she should do this at home whenever possible. In the
event a student must take medication at school, proper written consent must be given to school
personnel to administer the medication. Please note the following:
● No medication including prescription, over-the-counter, or herbal remedies will be
administered by school personnel or its agents until the consent forms are completed
and on file with the school.
● All medication must be in the original container.
● All prescription medication must have a pharmacy label including the student’s
name, correct dosage, and time(s) to be given.
● Parents are responsible for bringing medication to the school and picking up unused
medication within 10 days after the medication has been discontinued.
● Students are not allowed to transport their own medication. It must be brought to
school by the parent or guardian.
● School personnel may not cut tablets. If your child needs to receive half a tablet cut
the tablets at home or have the pills cut at the pharmacy filling the prescription.
● Please notify the school immediately, verbally and in writing, if there are any
changes to your child’s prescription.
The school may refuse to administer, or allow to be administered, any medication, which,
based on her/his assessment or judgment, has the potential to be harmful, dangerous or
inappropriate. In these cases, the school shall notify the parent/guardian and licensed prescriber and
explain the reason for refusal.
Please take the form on the next page to your child’s pediatrician to be completed. Each
medication requires a separate form. Bring the medication authorization form and the medication
to our collection day that will occur the week before the start of school. The collection date and
location will be announced this summer.
If you have any questions, concerns, or need information about medication administration at
school, please feel free to contact our school nurse at [email protected].
MEDICATION AUTHORIZATION FORM
Note: Each medication requires a separate form.
Parents complete this section:
Student Name __________________________________
Birthdate________________
Grade_____________
Parent/ Guardian 1____________________________ Email Address________________________________________
Home Phone________________________________ Cell Phone___________________________________________
Parent/Guardian 2 ____________________________ Email Address________________________________________
Home Phone_________________________________ Cell Phone___________________________________________
Physician Name ______________________________ Physician Number: ____________________________________
I hereby give permission for personnel designated by the principal to give this medication to my child according to the
directions stated. I also authorize school personnel designated in medication administration to contact my child’s
practitioner or myself if there is a question regarding medication administration. I agree to notify the school when the
drug is to be discontinued and/or the dosage or time changed. I understand that if the medication is resumed, a new
medication authorization form is required. I understand that any unused medication will be properly disposed of within
10 days if not claimed after discontinuation of the medication.
________________________________________________________________________________________________
(Parent or Guardian Signature)
Date
Physician completes this section for prescription and OTC medication:
Diagnosis/Reason for medication_____________________________________________________________________
Medication _____________________________________Dose _____________________________________________
Route/Mode of administration_____________________
Times to be given _____________________
Frequency________________________________________
Start date __________________
End date_________________
Duration (not to exceed current school year)_______________________________
Special instructions for administration _________________________________________________________________
Potential adverse reactions __________________________________________________________________________
I acknowledge with my signature on this document that I will assist and advise designated school personnel with regard
to the administration of medication described above, which includes accepting direct communication. I further
acknowledge that all instructions should be stated in language of the layperson.
________________________________________________________________________________________________
Practitioner Signature
Date
________________________________________________________________________________________________
Practitioner Name
Phone Number
Please place address stamp here:
State of California—Health and Human Services Agency
Primary Care and Family Health Division
Department of Health Services
Children’s Medical Services Branch
Child Health and Disability Prevention (CHDP) Program
REPORT OF HEALTH EXAMINATION FOR SCHOOL ENTRY
To protect the health of children, California law requires a health examination on school entry. Please have this report filled out by a health examiner and return it to the school. The school will keep and
maintain it as confidential information.
PART I
TO BE FILLED OUT BY A PARENT OR GUARDIAN
CHILD’S NAME—Last
First
ADDRESS—Number/Street
City
PART II
Middle
BIRTHDATE—Month/Day/Year
ZIP Code
SCHOOL
TO BE FILLED OUT BY HEALTH EXAMINER
HEALTH EXAMINATION
IMMUNIZATION RECORD
NOTE: All tests and evaluations except the blood lead test
must be done after the child is 4 years and 3 months of age.
Note to Examiner: Please give the family a completed or updated yellow California Immunization Record.
Note to School: Please record immunization dates on the blue California School Immunization Record (PM 286).
REQUIRED TESTS/EVALUATIONS
Health History
Physical Examination
Dental Assessment
Nutritional Assessment
Developmental Assessment
Vision Screening
Audiometric (hearing) Screening
Tuberculin Test (Mantoux/PPD)
Blood Test (for anemia)
Urine Test
Blood Lead Test
Other
PART III
DATE EACH DOSE WAS GIVEN
DATE
VACCINE
First
Second
Third
Fourth
Fifth
POLIO (OPV or IPV)
DTaP/DTP/DT/Td (diphtheria, tetanus, and [acellular] pertussis)
OR (tetanus and diphtheria only)
MMR (measles, mumps, and rubella)
HIB MENINGITIS (Haemophilus Influenzae B)
(Required for child care/preschool only)
HEPATITIS B
VARICELLA (Chickenpox)
OTHER
OTHER
ADDITIONAL INFORMATION FROM HEALTH EXAMINER (optional)
and
RELEASE OF HEALTH INFORMATION BY PARENT OR GUARDIAN
RESULTS AND RECOMMENDATIONS
Fill out if patient or guardian has signed the release of health information.
I give permission for the health examiner to share the additional information about the health check-up
with the school as explained in Part III.
!
Examination shows no condition of concern to school program activities.
!
!
Conditions found in the examination or after further evaluation that are of importance to schooling
or physical activity are: (please explain)
Please check this box if you do not want the health examiner to fill out Part III.
➤ _________________________________________________________
Signature of parent or guardian
__________________
Date
Name, address, and telephone number of health examiner
➤ _________________________________________________________
Signature of health examiner
PM 171 A (1/01) (Bilingual)
If your child is unable to get the school health check-up, call the Child Health and Disability Prevention (CHDP) Program in your local health
department. If you do not want your child to have a health check-up, you may sign the waiver form (PM 171 B) found at your child’s school.
__________________
Date
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
Child’s race/ethnicity:
□ White
□ Black/African American
□ Hispanic/Latino
□ Asian
□ Native American □ Multi-racial
□ Other___________
□ Native Hawaiian/Pacific Islander □ Unknown
Parent/Guardian Name:
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)
Visible Decay
Present:
Treatment Urgency:
□ No obvious problem found
□ Early dental care recommended (caries without pain or infection;
□ Yes
□ Yes
□ Urgent care needed (pain, infection, swelling or soft tissue lesions)
□ No
□ No
Licensed Dental Professional Signature
or child would benefit from sealants or further evaluation)
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
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.
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.
Albert Einstein Academy Kindergarten Requirements Checklist
◽
◽
◽
◽
Copy of a current immunization card. These vaccines are required for your child to attend public
school:
●
5 doses DTaP (diphtheria tetanus pertussis) except that a total of 4 doses is acceptable
if at least one dose was given on or after the 4th birthday
●
4 doses of Polio (IPV) except that a total of 3 doses is acceptable if at least one dose
was given on or after the 4th birthday
●
3 doses Hepatitis B
●
2 doses MMR (measles mumps rubella) both given on or after the first birthday
●
1 dose of Varicella (chicken pox vaccine).
Copy of your child’s birth certificate
“Report of Health Examination for School Entry” form completed by a licensed physician.
“Oral health assessment” form completed by a licensed dentist.
If you have any health related question please feel free to contact the school nurse at
[email protected].
Odyssey Academy Beverly Hills
Free and Reduced Lunch Information
Dear Parent/Guardian:
Children need healthy meals in order to learn effectively. The Albert Einstein Academy offers
healthy meals every school day. Your children may qualify for free meals or for reduced price
meals:
●
If you now receive Food Stamps, California Work Opportunity and Responsibility to Kids
(CalWORKs), Kinship Guardianship Assistance Payments (Kin-GAP), or Food
Distribution Program on Indian Reservations (FDPIR) benefits, your child may receive
free meals.
●
If your total household income is the same or less than the amounts on the income scale
found in the federal government reduced income eligibility guidelines
(http://www.gpo.gov/fdsys/pkg/FR-2012-03-23/pdf/2012-7036.pdf) your child may
receive meals free or at a reduced price. Household means a group of related or nonrelated individuals who are living as one economic unit and sharing living expenses.
Living expenses include rent, clothes, food, doctor bills, and utility bills.
●
A foster care child who is the legal responsibility of the welfare agency or ward of the
court may be eligible to receive meals free or at a reduced price regardless of your
income. Foster children must have a separate application from other children in your
household, and their eligibility is based on their “Personal Use Income.”
HOW TO APPLY
Contact the school for an Application for Free and Reduced-Price Meals or Free Milk, and
return it to the school as soon as possible. The application cannot be approved and may be
returned if it contains incomplete eligibility information.
CONFIDENTIALITY
Family size, household income, and Social Security number information will remain confidential
and will not be shared for any purpose. Information you provide will determine your
child/children’s’ eligibility to receive free or reduced-price meals.
You will be notified by the school when your application has been approved or denied for free or
reduced-price meals.