Please Complete the Attached Application and Return to OLV School Office

Please complete the attached application and return to OLV School Office.

Applications are considered complete when all materials are returned.

Blessings,

OLV School

OFFICE CHECKLIST: $25/child Testing Fee Birth Certificate Baptismal Communion Immunization Report Card  Test Scores HLS Reg. Fee

School Year 2017-2018

APPLICATION FOR GRADE ______(Grade child will be in for 2017-2018 school year)DATE ______

______/______/______

STUDENT’S LAST NAME FIRST MIDDLE PLACE OF BIRTH BIRTHDATE SOC SEC #

______

LEGAL LAST NAME (if different)

ADDRESS:PHONE:

______(______)______U.S. CITIZEN: YES  NO GENDER:  M  F

ETHNICITY: ______PRIMARY LANGUAGE SPOKEN AT HOME: ______

SCHOOL STUDENT NOW ATTENDS:ADDRESS: GRADE:

______

Do you have any tuition money due to another school for this student? (if so, please provide explanation)______

********************************************************************************* FAMILY INFORMATION *************************************************************************

LEGAL CUSTODY: CHILD RESIDES WITH: BOTH PARENTS FATHER MOTHER GUARDIAN - relationship: ______

FATHER (NATURAL)MOTHER (NATURAL) ADOPTIVE, STEP, or FOSTER PARENT, GUARDIAN

NAME
HOME/CELL PHONE
EMAIL
ADDRESS
BIRTHPLACE
CITIZEN / US: OTHER: / US: OTHER: / US: OTHER:
RELIGION
ETHNIC HERT.
OCCUPATION
WORK PHONE
DECEASED / DECEASED

BROTHERS/SISTERS WHO ATTEND(ED) OLV SCHOOL:OTHER RELATIVES WHO ATTEND(ED) OLV SCHOOL: YOUNGER SIBLING WHO MAY ATTEND OLV IN FUTURE (include name and current age):

______

Contact information (phone, email, address, etc) forrelatives who have attended OLV:

______

*********************************************************************************SACRAMENTAL RECORD***********************************************************************************

BaptismFirst Holy CommunionConfirmation

Date______

Church______

City, State, Country______

Verified by______

If child is not Catholic:Is child baptized?______Religion:______

Parish Affiliation:

Parish in which you live______Parish Church you attend______

*********************************************************************HEALTH/MEDICAL INFORMATION***********************************************************************************

Does your child have any medical, physical or emotional problems that may, in any way, affect his/her performance in school or school activities? Please describe:

______

Is your child using medication prescribed by a doctor for a specific condition? If so, please describe:

Condition:______

Medication/Dosage and Side Effects:______

Emergency Procedures Regarding Medication or Condition: ______

Physician: ______

******************************************************************ADDITIONAL INFORMATION NEEDED*******************************************************************************

Why do you wish for your child to attend a Catholic School? ______

______Along with this form please be sure to submit the following in order to complete your application:

$25 per child testing fee

Copy of Birth Certificate

Copy of Baptismal Record (if Catholic) and Copy of 1st Communion Record (if Catholic grades 3 and up)

Copy of Immunization and Health Record (for K only)

Completed Home Language Survey

Report Card and Standardized test scores (grades 3 and up)

Note that after acceptance to OLV School families must pay registration fee, apply for financial aid, and sign up for tuition management through the TADS online system.

Application Revised December 2016

2017-2018 Tuition Information

Please keep this page for your information.

2017-2018 Non-Refundable Registration Fees:

New Students - $100 per child
Returning Students (non 8th or non Catholic 2nd grade) - $100 per child
8th Grade Catholic Students (includes class sweater, graduation, and confirmation) - $300
8th Grade Non-Catholic Students (includes class sweater and graduation fee) - $220
2nd Grade Catholic or any student participating in 1st Communion in spring 2017 - $150

New student registration due upon acceptance to OLV School.

Returning student registration DUE APRIL 7, 2017

2017-2018 Tuition Rates:

Number of Children / One / Two / Three / Four
Participating Families (TADS Required)
School & Tuition Fees / $4,550 / $8,100
(1st child 4,550 +2nd child 3,550) / $11,150
(1st child 4,550 + 2nd child 3,550 +3rd child 3,050) / $13,700
(1st child 4,550 + 2nd child 3,550 + 3rd child 3,050 + 4th child 2,550)
Non-Participating Families (TADS Required)
School & Tuition Fees / $4,850 / $8,700 / $12,050 / $14,900
Non TADS this rate is only for families if they will not fill out TADS financial aid application. It is the full cost of education per child reflecting the whole cost to send children to OLV School without the assistance of the DOCF Subsidy. / $9,500 / $19,000 / $28,500 / $38,000

Methods of Payment

There are two options offered for payment of tuition.

Option 1–full payment as automatic bank withdrawal, cash, or check payable to OLV. Note that even if you pay through cash or check, you will still have a TADS tuition management account. Families who pay the full tuition rate and can make full payment on or before August 1, 2017 will receive a $100 discount on tuition. The discount is only available to those paying the full tuition amount.
Option 2–ten monthly payments through your TADS tuition management account. You are encouraged to pay this account through direct automatic bank withdrawal set up through TADS, however cash and checks brought into OLV School office can also be credited to your monthly payments.

This year there will be no extra fee for the TADS financial aid application or tuition management account through TADS.

Date/日期/ Fecha:
Student’s Name/學生姓名/
Nombre del estudiante:
Student’s Grade/學生年級/
Grado del estudiante:
School Site/學校/ Escuela:
School Address/學校地址/
Direccion de la Escuela:

Which language did your child first learn when s/he began to talk?

貴子女最初學講何種語言？¿Quéidiomaaprendióprimerocuandocomenzó a hablar el estudiante?

Which language do you use most frequently to speak with your child?

閣下常用何種語言與貴子女交談？¿En quéidioma le habla al estudiante con másfrecuencia?

Which language does your child use most frequently at home?貴子女在家中常用何種語言？¿Quéidiomahabla con másfrecuencia el estudiante en suhogar?

Which language do the adults use most frequently at home?家中各成年人常用何種語言交談？¿Quéidiomahablan con másfrecuencia los adultos en el hogar?

Parent/Guardian Name (print name)/家長／監護人（請用正楷填寫家長／監護人姓名) / Padre/Madre/ Encargado/a (escribasunombre):
Parent/Guardian Signature/家長／監護人簽署/Firma del/a padre/madre/encargado/a:

SFUSD Curriculum & Instruction, Multilingual Pathways Department

750 25th Avenue, San Francisco, California, 94121 (415) 379-7773

Home Language Survey version: August 2016-2017 SY

San Francisco Unified School District - School Health Form

Completed by Parent or Caregiver:

Child’s Name: / ______ / Birthdate: / ______ / Male / Female / School: / ______
Last, First / month/day/year
Address: / ______ / Phone: / ______/ ______/______ / Grade: / ______
Street / Zip / Home / Cell / / Work

Release of Health Information: I give permission to share the results of this examination with the School ______

Signature of Parent/Caregiver Date

NOTE: Kindergarten entrance physical examination to be done no earlier than March of the year the child enters Kindergarten

Completed by health provider:

IMMUNIZATION RECORD (EACH child should have a completed or updated official/ yellow Immunization Record)

Dose given Month / Day / Year / Tuberculin Skin Test (Mantoux/PPD)
Date: ______

Vaccine

/ 1st / 2nd / 3rd / 4th / 5th
Polio: / Induration: _____mm Impression: □ Negative □ Positive
DTaP/DT (Diphtheria, Pertussis, Tetanus) / Chest X-Ray/RX: required with Positive TB Skin Test
CXR Date:______Impression: □ Negative □ Positive
Td/Tdap (Tetanus, Diphtheria, Pertussis)
Hib (Haemophilus influenza type B) / RX treatment & duration: _____ / ______
MMR (Measles, Mumps, Rubella) / Not to be given before the 1st birthday /  Child has no risk factors for TB and does not require TB test
*see back for risk factors
Health Provider Signature
Hepatitis B
Varicella (Chickenpox) / Had Varicella disease - Approximate date ______

HEALTH EXAMINATION – Date of Exam______

Results: / Relevant findings: / Follow-up/Referral Needed :
Health/Developmental History
Physical Examination / Ht: ______BP: ______
Wt: ______BMI: ______%
Dental Assessment
Developmental Evaluation
Vision Screening / R: 20/__ L: 20/__
Audiometric (hearing) Screening / 500 / 1000 / 2000 / 4000
Right:
Left:
Nutritional Assessment
Lab Tests / Urine____ Lead ____ Blood test for anemia______
Other

(If you do not want your child to have an exam, you may sign the waiver form, PM 171B, obtained from your child’s school) See other side for more details.

Examination revealed no condition relevant to the school program, e.g. allergies, asthma, cardiac condition, diabetes, epilepsy, etc.

Medical condition identified – emergency care plan attached (emergency care plan template can be downloaded at

Medication taken at school – Name of medication: ______Medication taken at home – Name of medication: ______

(If medication is taken at school, complete a medication form for each medication (medication form template can be downloaded at

Restriction from physical activity – please specify______
Name of Health Provider:
Address:
Phone: / Child under my care since ______.
Signature of Health Provider:______Date: ______

SFUSD School Health Form 2008/2009Page 1

GUIDE TO IMMUNIZATIONS REQUIRED FOR SCHOOL ENTRY

Grades K-12

REFERENCE: Health and Safety Code, Division 105, Part 2, Chapter 1, Sections 120325-120380; California Code of Regulations, Title 17, Division 1, Chapter 4, Subchapter 8, Sections 6000-6075

IMMUNIZATION REQUIREMENTS: To enter or transfer into public and private elementary and secondary schools (grades kindergarten through12), children under age 18 years must have immunizations as outlined below.

VACCINE / REQUIRED DOSES
Polio / 4 doses at any age, but... 3 doses meet requirement for ages 4–6 years if at least one was given on or after the 4th birthday; 3 doses meet requirement for ages 7–17 years if at least one was given on or after the 2nd birthday.
Diphtheria, Tetanus, and Pertussis
Age 6 years and under
DTaP/DT (diphtheria, tetanus, pertussis)
Age 7 years and older (Pertussis is not required)
Td/Tdap
7th grade
Td/Tdap booster / 5 doses at any age, but... 4 doses meet requirements for ages 4–6 years if at least one was on or after the 4th birthday.
4 doses at any age, but...3 doses meet requirement for ages 7–17 years if at least one was on or after the 2nd birthday. If last dose was given before the 2nd birthday, one more (Td/Tdap) dose is required.
1 dose not required but recommended if more than 5 years have passed since last DTap, DT or Td dose.
Measles, Mumps, Rubella (MMR)
Kindergarten
7th grade
Grades 1–6 and 8–12 / 2 dosesboth on or after 1st birthday.
2 dosesboth on or after 1st birthday.
1 dose must be on or after 1st birthday.
Hepatitis B
Kindergarten
7th grade / 3 doses at any age
3 dosesat any age or 2 doses of 2 dose formulation
Varicella
Kindergarten
Out-of-state entrants (grades 1–12) / 1 dose
1 dose for children under 13 years; 2 doses are needed ifimmunized on or after 13th birthday.

EXEMPTIONS: The law allows (a) parents/guardians to choose an exemption from immunization requirements based on their personal beliefs, and (b) physicians of children to elect medical exemptions. The law does not allow parents/guardians to elect an exemption simply because of inconvenience (a record is lost or incomplete and it is too much trouble to go to a physician or clinic to correct the problem). See the back of the blue California School Immunization Record (PM 286) for instructions and the affidavit to be signed by parents/guardians electing the personal beliefs exemption. For children with medical exemptions, the physician's written statement should be stapled to the CSIR. Schools should maintain an up-to-date list of pupils with exemptions, so they can be excluded quickly if an outbreak occurs.

TB Skin Test (with result)……Given in the United States within 1 year before first admission to school in San Francisco

Signature of examiner attesting to no risk factors for TB

Risk Factors for TB in Children

Have a family member or contacts with history of confirmed or suspected TB
Are in foreign-born families and from high-prevalence countries (Asia, Africa, Central and South America)
Adopted from any high-risk area
Travel to countries with high rate of TB
Live in out-of-home placements
Have, or are suspected to have, HIV infection
Live with an adult with HIV seropositivity
Live with an adult who has been incarcerated in the last five years
Live among, or are frequently exposed to, individuals who are homeless, migrant farm workers, users of street drugs, or residents of nursing homes
Have contact with individuals(s) with positive TB skin test(s)
Have abnormalities on chest X-ray suggestive of TB

Have clinical evidence of TB

Screening should be performed by CXR in addition to skin test and symptom review in HIV infected or suspected HIV, other immunocompromised conditions or if child is taking immunosuppressive agents such as chronic predisone or TNF blockers

THE KINDERGARTEN/FIRST GRADE HEALTH EXAMINATION

A completed physical is required for children entering school. The physical examination of kindergarten must be done after March 1st for the same year that they entered school. First graders, the examination must be done not more than 18 months prior to entry. Lack of evidence of a physical examination will result in denial of enrollment.

SFUSD - School Health Form 2008/2009Page 2