Westmont High School is Going Green!

Instead of our regular mailing of registration materials for returning and pre-registered students, we
will be providing all the documents you need on-line. This saves money for the school and will also
make it easier for you to access Westmont’s registration materials.

The registration packet consists of two PDF (electronic format) files: One contains general
information such as the Principal’s letter, Parent Handbook, etc. The other contains all the documents
necessary for your student to obtain their class schedule in August. You need to print out the
documents according to the instructions and have your student bring them to school on the appointed
dates and times in order for them to receive their class schedule.

If you have any questions or concerns, please contact Westmont at 408-626-3406 or the district office
at 408-371-0960.
 Westmont High School
Class Schedule Pick-up Information
rd
School starts on August 23
If you are unable to pick up your schedule at the appointed date and time, please call the
school at 626-3406. Student must be present to pick up their schedule. Class schedules
cannot be picked up by a parent/guardian.

Tuesday, August 17th:

Class of 2011 (Seniors) 8:00 to 10:00 AM

Class of 2012 (Juniors) 1:00 to 3:00 PM

Wednesday, August 18th

Class of 2014 (Freshmen) Camp Westmont 8:00 AM to Noon

Freshmen Orientation – Meet in the Stadium
Parking Lot
Class of 2013 (Sophomores) 1:00 to 3:00 PM

All forms must be turned in and any outstanding fees paid in order to receive your
class schedule. A letter was mailed recently indicating any fees/book bills due or you
may call the office to determine if there are any outstanding fees/book bills.

______ Pay any outstanding fees or return books in the main office.
The main office opens on August 2nd. Office hours are 7:30 to 3:30
(closed 12:00 to 1:00)

______ Forms required prior to getting your class schedule:

a) Registration Card
b) Emergency Card
c) Free and Reduced Lunch form (required by state, if you do not qualify,
please write your name on the form and “DOES NOT QUALIFY”
across the form)
d) Internet Permission Form
e) Software Code of Ethics

_____ Optional Forms:

a) Westmont ASB/PTSA Registration Form

b) Westmont PTSA Volunteer Opportunities
c) PTSA Membership Form
d) The Shield (School Newspaper) Subscription Form
e) Len Conrad School Picture Order Form (only if you want to buy
school picture, payment is required with order form)
f) PTSA Bowling League Registration Form
Campbell Union High School District REGISTRATION CARD Home School:_______________________ School Year:_______

Student Name: _____________________________________________________________________ Male ____ Female ____ Grade _____

Last First Middle

First Name Preference: ________________________________________ E-mail address:______________________________________________

Date of Birth: ___/____/_____ Birth City: ____________________________ State: __________ Country: ___________________________

Student’s Address:__________________________________ Apt.#:______ ___________________ ____________ ______________________

Street City Zip Home Phone #

Father /Guardian: (student living with? Yes ___ No ___) Employed by:________________________________________________
Name: ____________________________________________________ Address: _________________________________________________
Address: _________________________________________Apt.#_____ City: _____________________________ Phone:____________________
City: ____________________________ State: _____ Zip ___________ Cell # ____________________________ Pager # __________________
Phone: _____________________________ E-mail address: ___________________________________________

Mother /Guardian : (student living with? Yes ___ No ___) Employed by:_______________________________________________
Name: ____________________________________________________ Address: _________________________________________________
Address: _________________________________________Apt.#_____ City: _____________________________ Phone:____________________
City: ____________________________ State: _____ Zip ___________ Cell # ____________________________ Pager # __________________
Phone: ____________________________ E-mail address:______________________________________________

School Attended Last Year: _______________________________________________ District: __________________________________________

Address: ______________________________________________________________ City: ___________________________ State: ___________

The Campbell Union High School District is required to notify parents and guardians of their rights to excuse Students from specific activities and to
obtain education for the handicapped (Education Code Section 48980). These rights are printed on a separate sheet accompanying this form. Your
signature below indicates that you have seen this notice but does not imply consent to participate in any particular program.

State and Federal Education Programs require the submission of the information requested below. Your cooperation in helping us meet
this important requirement is requested. Please answer the following questions and have your son/daughter return this form to the
high school.

ETHNICITY: Is this student Hispanic or Latino?

Correspondence Language:
English Spanish
FOREIGN BORN STUDENTS ONLY:
Date student first entered the
Yes No
Check the ones that apply to you:
RACE: In addition to the Ethnicity question
above, you MUST check at least one of the Do not share student information with
race boxes below. Military recruiters.

U. S.:_____/_____/_______ 100 - American Indian or Alaska Native I have read and agree to the policy
201 - Chinese on Internet Usage/And Software
Since entering, has student left 202 - Japanese Code of Ethics.
the U.S. for any long period of 203 - Korean
time? Yes No 204 - Vietnamese I have read and agree to the policy
205 - Asian Indian on Locker Usage.
Is the student a U.S. Citizen: 206 - Laotian
Yes No 207 - Cambodian
208 - Hmong Check the Appropriate Box that
If no, give Immigration number: 299 - Other Asian Applies to the Parent with the
# _____________________ 301 - Hawaiian Highest Level of Education.
302 - Guamanian
Date student first entered 303 - Samoan 1. Not a high school graduate
U.S. schools:____/____/_____ 304 - Tahitian 2. High school graduate
399 - Other Pacific Islander 3. Some college(includes AA degree)
Date student first entered Calif. 400 - Filipino 4. College graduate(four year degree)
schools: _____/_____/______ 600 - Black or African American 5. College post graduate
700 - White 6. Declined to state/Unknown

_____________________ _____________________________________________________________________
Date Signature of parent or guardian
W-90 CAMPBELL UNION HIGH SCHOOL DISTRICT
EMERGENCY CARE CARD Year in School
___________________________________________________________________________ Fr. So. Jr. Sr.
Student’s Name (Last) (First) (Initial) (Circle one)

Address Street # Apt. # Birthdate _____/_____/______

_________________________________________ _______________ _______________ Male_______ Female________
City Zip Home Phone
_____________________________________ _____________ ____________________________________ _____________
Father/Guardian(Living with? Yes___ No___) Work Phone Mother/Guardian(Living with? Yes___ No___) Work Phone
Cell # ____________________ Pager # ___________________ Cell # _____________________ Pager # _________________

IN CASE OF AN EMERGENCY, IF NEITHER OF THE ABOVE CAN BE LOCATED, PLEASE NOTIFY:

Name: Relationship Address Day Phone:
1) __________________________________ ___________ _________________________________________ __________
2) __________________________________ ___________ _________________________________________ __________
3) __________________________________ ___________ _________________________________________ __________
4) __________________________________ ___________ _________________________________________ __________

I do Give my consent for emergency medical treatment if the listed persons cannot be reached. I realize that the school
I do not district cannot assume responsibility for the payment of medical fees, transportation, or expenses incurred.

Signature of Parent/Legal Guardian ________________________________________________ Date ________________________

Special Health Problems or Concerns – Please See Reverse Side

Health Conditions – Circle those that apply

Is your child DIAGNOSED with:
ASTHMA: YES NO * Carries inhaler at school* *Yes* No (Form must be on file, see below)
ALLERGIES: _____________________________ *EPIPEN at School: *Yes* No (Form must be on file, see below)
DIABETES: Type: ______________ Blood testing at School *Carries Insulin* Emergency Protocol on File
SEIZURES: Type: ______________________________ Date of last seizure: ________________________

_____________________________________ ______________
Family Doctor Phone
_____________________________________ ______________ ______________________________________ ______________
Family Dentist Phone Health Insurance Provider Policy #

List any diagnosed health problems:

________________________________________________________________________________________________________

* Permission forms to carry and/or take medication at school must be completed and on file in the Health Office prior to dispensation.
Forms can be obtained in the Health Office. (California Education Code Section 49423)
Name: _________________________________________________________________ Grade: __________
LAST FIRST

Campbell Union High School District

ACCEPTABLE USE POLICY

FOR INTERNET / E-MAIL AND COMPUTER USE

Use of the Internet, e-mail and computer services provides great educational benefits to students. Unfortunately,
some material accessible via the Internet may contain items that are illegal, defamatory or potentially offensive
to some people. Access to the Internet, e-mail and other computer activities are given as a privilege to students
who agree to act in a considerate and responsible manner. We require that students read, accept and sign the
following rules for acceptable on-line behavior.

1. Students are responsible for good behavior on the Internet just as they are in a school building. General
school rules for behavior and communications apply.

2. Network administrators may review files and communications to maintain system integrity and ensure that
users are using the system responsibly.

USERS SHOULD NOT EXPECT THAT FILES WILL ALWAYS BE PRIVATE:

3. The following are not permitted:

• Sending or displaying offensive messages or pictures

• Using obscene language
• Harassing, insulting, or attacking others
• Damaging computers, computer systems, or computer networks
• Violating copyright laws
• Using another’s password
• Trespassing in another’s folders, work, or files
• Intentionally wasting limited resources, including the use of “chain letters” and messages, broadcasted
to mailing lists or individuals
• Employing the network for commercial purposes
• Revealing the personal address or phone number of yourself or any other person without permission
from your teacher
• Downloading files or games without permission from your teacher

4. Violations may result in a loss of access as well as other disciplinary or legal action.
 Campbell Union High School District
CODE OF ETHICS
STUDENTS
All employees and students of the Campbell Union High School District shall use software only in accordance
with its license agreement. Unless otherwise note in the license, any duplication of copyrighted software –
except for back up and archival purposes, is a violation of federal law and CUHSD policy. This signed Code of
Ethics will be filed with the student’s record at each school, each year.

1. I will use software according to the provisions of the license agreements

2. I will not make unauthorized copies of software under any circumstances
3. I recognize that the CUHSD will not tolerate nor allow the use of any illegal software copies on its
computers.
4. I understand that anyone found copying software other than for backup or archival purposes is subject to
disciplinary actions up to and including dismissal or expulsion.
5. I understand that anyone found making illegal software copies might be subject to civil and criminal
penalties up to $250,000 per work copies and/or expulsion for CUHSD.
6. I will report any suspicious misuse of software to the District’s Director of Technology Services or the
school Technology Coordinator.

I have read and reviewed the CUHSD Acceptable Use Policy and Software Code of Ethics for Students and
fully intend to comply with its content. Should I violate those rules, I understand my privilege to use the school
district account may be revoked at any time.

THIS AGREEMENT shall be in effect between the student and the Campbell Union High School District for
four years or until we are notified in writing that it is to be terminated:

STUDENT SIGNATURE: ________________________________________________ Date: __________

As the parent/guardian of ________________________________________________________

PLEASE PRINT STUDENT’S NAME (LAST, FIRST)

I have read this agreement and understand that the Internet account, e-mail or other computer services are
designed for educational purposes only. I also understand that it is impossible for the school to restrict access to
controversial materials.

Therefore, I will not hold the teacher, the school, or the CUHSD responsible for or legally liable for materials
distributed to or acquired from the network. I also agree to report any misuse of the information system to the
system administrator or teacher.

I have read and reviewed the Campbell Union High School Acceptable Use Policy and I realize and accept that
should my student violate this Agreement that his/her privileges to use a district account may be restricted or
even terminated:

_____________________________________________________ _______________
Parent/Guardian Signature Date

DON’T FORGET TO ALSO SIGN THE REGISTRATION CARDS

California Department of Education
Nutrition Services Division
Campbell Union High School District
DIRECTIONS FOR FILLING OUT YOUR APPLICATION FOR FREE AND
REDUCED-PRICE MEALS FOR SCHOOL YEAR 2010-2011
Please complete the application attached, sign the application, and return it to your child's school or to the food service department.
INFORMATION NEEDED:
• The name of the child or children for whom you are applying for free or reduced-price benefits
• The names and income of all other household members
• The signature of the child's or children's parent or guardian
• The Social Security number of the person who signed the application. If the person signing the application does not have a
social security number, write "none" in the space provided.

ALL HOUSEHOLDS: READ THIS SECTION

California Education Code Section 49557(a): Applications for free and reduced-price meals may be submitted at any time
during a school day. Children participating in the National School Lunch Program will not be overtly identified by the use
of special tokens, special tickets, special serving lines, separate entrances, separate dining areas, or by any other
means.

Privacy Act Statement: National School Lunch Act (Section 9) requires that, unless your child's Food Stamp, California
Work Opportunity (CalWORKs), Kinship Guardian Assistance Payment (Kin-GAP), or Food Distribution Program on Indian
Reservations (FDPIR) case number is provided, you must include the social security number of the adult household
member signing the application or indicate that the household member signing the application does not have a Social
Security number. Provision of a social security number is not mandatory, but the application cannot be approved if a
social security number is not provided or an indication is not made that the signer does not have such a number. The
social security number may be used to identify the household member in carrying out efforts to verify correct information
provided on the application. These verification efforts may be carried out through program reviews, audits, and
investigations and may include contacting employers to determine income, contacting the State’s Employment
Development Department or local welfare offices to determine the amount of benefits received, and checking the
documentation produced by household members to prove the amount of income received. Reporting incorrect
information may result in loss or reduction of the household’s program benefits, or in administrative claims and/or legal
actions against household members.

In accordance with federal law and U.S. Department of Agriculture (USDA) policy, this institution is prohibited from discriminating on the basis
of race, color, national origin, sex, age, or disability.
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue,
W, Washington, D.C. 20250-9410 or call (202) 720-5964 (voice and TDD). The USDA is an equal opportunity provider and employer.
California Department of Education
Nutrition Services Division

Campbell Union High School District

INSTRUCCIONES PARA COMPLETAR SU APLICACIÓN PARA COMIDAS ESCOLARES GRATIS Y A PRECIOS
REDUCIDOS EN ANO 2010-2011

Por favor completa el aplicación adjunto, firma el aplicación, y regresa a la escuela o el departmento servicios comidas al distrito.
INFORMACIÓN NECESARIO:
• El nombre del estudiante(s) y que escuela asiste
• Los nombres y sueldos trabajos para todo otro miembros de la casa
• Firma del pariente or guardian del estudiante(s)
• El Numero Seguro Social del persona que firma este aplicación. Si no tiene un number seguro social, por favor escriba la
palabra ‘NONE’ en el espacio previsto

TODOS LOS HOGARES DEBERAN LEER Y COMPLETAR ESTA SECCION:

Sección 49557(a) del Código de Educación de Califórnia: La solicitud para las comidas gratis o a precios reducidos
puede ser enviada en cualquier momento durante el día escolar. Los niños que participen en el Programa Nacional de
Alimentos Escolares, no se les distinguirá con el uso de fichas especiales, boletos especiales, filas especiales de
servicio, entradas separadas, comedores separados, o otra forma de discriminación.

Programa Nacional de Alimentos Escolares de la Ley Federal (Sección 9) requiere que Ud., al menos que anote el
número del caso de Estampillas de Comida, CalWORKs, Kin-GAP, o FDPIR de su hijo(s), tiene que incluir el número
del Seguro Social del adulto miembro del hogar que firma la solicitud o indicar que el miembro del hogar firmando la
solicitud no tiene un número del Seguro Social. No es obligatorio dar el número del Seguro Social, pero si no se
proporciona un número del Seguro Social o no se indica que el que firma no tiene tal número, la solicitud no puede
ser aprobada. El número del Seguro Social puede ser usado para identificar al miembro del hogar para luego poder
verificar la información indicada en la solicitud. Estos esfuerzos de verificación pueden ser realizados por medio de
revisión del programa, comprobación de recibos y cuentas, e investigaciones; y pueden incluir contacto con patrones
para determinar ingreso, contacto con la Oficina de Desarrollo de Empleos del Estado (State’s Employment
Development Department) o agencias locales de asistencia social para determinar la cantidad de beneficios recibidos,
y para revisar la documentación producida por los miembros del hogar para luego comprobar la cantidad de ingreso
recibido. Proporcionar información incorrecta puede resultar en pérdida o reducción de beneficios, reclamo de
administración y/o acciones legales en contra de miembros del hogar.

Entiendo que toda la información en esta solicitud es verdadera y correcta, y que todos los ingresos son
declarados. Entiendo que esta información es para el recibo de fondos federales; que las autoridades
escolares pueden verificar la información de esta solicitud; Y que la falsificación deliberada de datos, me
expone a ser enjuiciado /a conforme a las leyes federales y estatales pertinentes.
 Campbell Union High School District FOR SCHOOL USE ONLY - ELIGIBILITY DETERMINATION

SOLICITUD PARA COMIDAS ESCOLARES GRATIS HOUSEHOLD SIZE: HOUSEHOLD INCOME: YEAR TRACK:10-11
Y A PRECIOS REDUCIDOS EN AÑO 2010/2011 FREE WITH: FS / CALWORKS / KIN-GAP / FDPIR DIRECT CERTIFIED AS: H M R
FREE: REDUCED: DENIED: 2ND REVIEW: EP: †
COMPLETE ESTA SOLICITUD Y REGRESELA
A LA ESCUELA or LA OFICINA SERVICIOS DE COMIDA TEMPORARY FREE UNTIL (45 DAYS FROM DATE OF DETERMINATION):
DETERMINING OFFICIAL: DATE:
VERIFICATION OFFICIAL: DATE:
SECCIÓN A : TODOS LOS NIÑOS DEL HOGAR DEBEN SER INCLUIDOS EN ESTA SECCION :
ESTAMPILLAS DE FOR
COMIDA (FS), CALWORKS, NIÑOS ADOPTADOS SCHOOL
INFORMACION DE ESTUDIANTES/NIÑOS
KIN-GAP O BENEFICIOSFDPIR FOSTER USE ONLY
ESCRIBA EL NÚMERO DEL ESCRIBA EL INGRESO
ESCUELA SI/ SI/
APELLIDO NOMBRE PRIMERO CASO FS, CALWORKS, PERSONAL MENSUAL STUDENT ID
(N/A, NINGUNA) NO NO
KIN-GAP, O FDPIR DEL NINO

1.
2.
3.
4.
SECCION B. INGRESO MENSUAL DE LOS MIEMBROS DEL HOGAR QUE VIVEN EN LA CASA: SI DECLARA EL NUMERO DE CASO DE ESTAMPILLAS
DE COMIDA, CalWORKs, Kin-GAP, o FDPIR, POR CADA NIÑO, o si la aplicación es para niño foster y Ud. Indico ingreso personal del niño, NO LLENE ESTA
SECCION, SIGA CON LA SECCIÓN C. Un niño adoptivo (foster) que esta bajo la responsabilidad legal de la agencia de welfare o corte puede recibir comida
gratis o a precios reducidos sin tomar en cuenta sus ingresos.
Escriba los nombres de todos los miembros adultos del hogar y indique la cantidad y el origen del ingreso que cada miembro recibió el mes
pasado. Si esto no refleja correctamente su ingreso mensual, proyecte su ingreso normal del mes. No llene esta sección si tiene para cada
niño de la sección el numero del caso de Estampillas de Comida, CalWORKs, Kin-GAP, o FDPIR. Firma la aplicación en la Sección C.
También incluye todos los ingresos recibidos de los adolescentes, ya sea por tiempo completo o parcial de trabajo, SSI, o asistencia de
adopción.
BENEFICIOS DE
SUELDOS DE TRABAJOS
PENSIONES, WELFARE, AYUDA FOR SCHOOL
(ANTES DE LAS CUALQUIER
APELLIDO PRIMER NOMBRE JUBILACIÓN, ECONOMICA PARA USE ONLY TOTAL
DEDUCCIONES) INCLUYA OTRO INGRESO
SEGURO SOCIAL NIÑOS, ASSISTENCIA MONTHLY INCOME
TODOS LOS TRABAJOS
DE DIVORCIO

1.
2.
3.
4.
SECCIÓN C. TODOS LOS HOGARES DEBERAN LEER Y COMPLETAR ESTA SECCION
Sección 49557(a) del Código de Educación de Califórnia: La solicitud para las comidas gratis o a precios reducidos puede ser enviada en cualquier momento
durante el día escolar. Los niños que participen en el Programa Nacional de Alimentos Escolares, no se les distinguirá con el uso de fichas especiales, boletos
especiales, filas especiales de servicio, entradas separadas, comedores separados, o otra forma de discriminación.
Programa Nacional de Alimentos Escolares de la Ley Federal (Sección 9) requiere que Ud., al menos que anote el número del caso de
Estampillas de Comida, CalWORKs, Kin-GAP, o FDPIR de su hijo(s), tiene que incluir el número del Seguro Social del adulto miembro del
hogar que firma la solicitud o indicar que el miembro del hogar firmando la solicitud no tiene un número del Seguro Social. No es
obligatorio dar el número del Seguro Social, pero si no se proporciona un número del Seguro Social o no se indica que el que firma no
tiene tal número, la solicitud no puede ser aprobada. El número del Seguro Social puede ser usado para identificar al miembro del hogar
para luego poder verificar la información indicada en la solicitud. Estos esfuerzos de verificación pueden ser realizados por medio de
revisión del programa, comprobación de recibos y cuentas, e investigaciones; y pueden incluir contacto con patrones para determinar
ingreso, contacto con la Oficina de Desarrollo de Empleos del Estado (State’s Employment Development Department) o agencias locales de
asistencia social para determinar la cantidad de beneficios recibidos, y para revisar la documentación producida por los miembros del
hogar para luego comprobar la cantidad de ingreso recibido. Proporcionar información incorrecta puede resultar en pérdida o reducción
de beneficios, reclamo de administración y/o acciones legales en contra de miembros del hogar.
Entiendo que toda la información en esta solicitud es verdadera y correcta, y que todos los ingresos son declarados. Entiendo que esta información es para el
recibo de fondos federales; que las autoridades escolares pueden verificar la información de esta solicitud; Y que la falsificación deliberada de datos, me expone a
ser enjuiciado /a conforme a las leyes federales y estatales pertinentes.
FIRMA DE ADULTO MIEMBRO DEL HOGAR QUIEN LLENA ESTA TELEFONO FECHA

IMPRIMA EL NOMBRE DEL ADULTO QUE FIRMA ESTA APLICACION ESCRIBA SU NUMERO DE SEGURO SOCIAL (SS#) AQUI, O ESCRIBA «NONE» SI USTED NO TIENE UNO

DOMICILIO

CIUDAD CODIGO POSTAL TOTAL NUMERO DE ADULTOS Y NINOS DEL HOGAR

SECCIÓN D. IDÉNTIDÁDES ÉTNICOS Y RACIÁLES DE NIÑOS (Opcional)

1. Apunté uno o mas identidades raciales: Indígena Americano o Asiático Negro o Hawaiano Nativo o otro Blanco
Nativo de Alaska Africano-Americano Islajero Pacífico
2. Apunté un identidad étnico: De origen Latino o Hispánico No de origen Latino o Hispánico

Esta institución es un proveedor igual de la oportunidad.

 APPLICATION FOR FREE AND REDUCED-PRICE MEALS
OR FREE MILK FOR SCHOOL YEAR 2010/2011
SECTION A. STUDENT INFORMATION: Complete this section by providing information for all of the children in your
household.
FOOD STAMP,
CALWORKS, KIN- FOSTER CHILD FOR SCHOOL
STUDENT / CHILD INFORMATION (MUST HAVE SEPARATE
GAP, USE ONLY
OR FDPIR BENEFITS APPLICATION)
CURRENT SCHOOL WRITE WRITE IF “YES,” ENTER
IF “YES,” WRITE
(WRITE "N/A" IF “YES” “YES” CHILD’S MONTHLY
LAST NAME FIRST NAME CASE NUMBER STUDENT ID
NOT OR OR “PERSONAL-USE”
BELOW
IN SCHOOL) “NO” “NO” INCOME

SECTION B. HOUSEHOLD MEMBERS AND MONTHLY INCOME: If in Section A you entered a Food Stamp, CalWORKs,
Kin-GAP, or FDPIR case number for each child, or if this application is for a foster child and you entered monthly personal-use
income, go to signature block in Section C. Foster Child: In some cases foster children are eligible for free or reduced-price meals or
free milk regardless of the household's income. If you have foster children living with you and you wish to apply for meal or milk
benefits for them, please contact your school's food administrator.
List all adult household members, regardless of whether or not they have income. Indicate the amount and source of monthly income
each household member received last month. If any amount last month was more or less than usual, enter the usual monthly income.
Also, enter any income received by or for a child from full-time or regular part-time employment, Social Security Income, or Adoption
Assistance.
gross monthly
PENSION, WELFARE BENEFITS,
any FOR SCHOOL

FULL NAME
EARNINGS FROM WORK
RETIREMENT, CHILD SUPPORT,
other USE ONLY:
(BEFORE DEDUCTIONS) MONTHLY TOTAL MONTHLY
SOCIAL SECURITY ALIMONY PAYMENTS
INCLUDE ALL JOBS INCOME INCOME

SECTION C. I certify that all of the above information is true and correct and that all income is reported. I understand that this
information is given in connection with the receipt of Federal funds, that school officials may verify the information on the
application at any time, and that deliberate misrepresentation of the information may subject me to prosecution under applicable
State and federal laws.
SIGNATURE OF ADULT HOUSEHOLD MEMBER COMPLETING THIS FORM TELEPHONE NUMBER DATE

( )
PRINTED NAME OF ADULT HOUSEHOLD MEMBER WHO COMPLETED THIS SOCIAL SECURITY NUMBER (WRITE “NONE” IF N/A)
FORM

MAILING ADDRESS

CITY ZIP CODE TOTAL ADULTS AND CHILDREN IN HOUSEHOLD

SECTION D. CHILDREN’S RACIAL AND ETHNIC IDENTITIES (Optional):

1. Mark one or more racial identities:
American Indian or Asian Black or Native Hawaiian or White
Alaska Native African American Other Pacific Islander
2. Mark one ethnic identity: Of Hispanic or Latino origin Not of Hispanic or Latino origin
FOR SCHOOL USE ONLY - ELIGIBILITY DETERMINATION
Free Reduced Denied Categorically Free with Food Stamp, CalWORKs, Kin-GAP, or FDPIR Benefits

Zero Income, Temporary Free Until (Up to 45 calendar days from date of this determination): Direct Certified as: H M R EP
Year Round Track: 10/11 Household Size: Household Income:
Determining Official: Date: 2nd Review – Official: Date:
Verification Official: Date: Follow up:
Rev. June 2005