Universal Form
Please fill out the form and click the send button. You will be required to fill out a paper Universal Form once school reopens. Thank you.
Email address *
Student Name (last name, first name) *
Parent Name (last name, first name) *
Address, City, State, Zip Code *
Home/Cell Phone *
Work Phone
School *
Required
Grade *
After reviewing the Facts for Parents booklet, student and parent/guardian must check each question, sign the last section and return this form to the school office.
1. DISCRIMINATION, HARASSMENT & BULLYING (Facts for Parents: Section B). By checking each circle below, I acknowledge the following: *
Required
2. PHOTOGRAPHY/VIDEO/MEDIA RELEASE* During the school year, schools host events where representatives of the news media may be on campus to gather photographs and/or video footage. In addition, parents and students may take photos of events in classrooms or around schools. These photos may be posted on the Internet, on social media or otherwise distributed without the permission of the school. Your child's participation in these events is valued and parent permission is needed to include him or her in events where photography may take place. Parents/Guardians who prefer that their child not be photographed or video recorded must notify their school by using this form. Schools make every effort to ensure the wishes of the parent/guardian. Please be aware that photographing and video recording by devices such as a mobile phone may take place without the knowledge of the teacher, principal or district staff. PARENTS OR GUARDIANS: Indicate your level of permission OR use the last circle to opt out completely. I give my permission (select all that apply): *
Required
3. UNIFORM DISCIPLINE PLAN (Facts for Parents: Section C) *
Required
4. HEALTH REQUIREMENTS (Facts for Parents: Section D). California law requires that parents/guardians of each pupil acknowledge having been informed of their rights as explained in the "Health Requirements" in Facts for Parents. *
Required
5. LEA MEDI-CAL BILLING PROGRAM (Facts for Parents: Section F). The District, in cooperation with the California Department of Health Care Services and Education, participates in a program that allows the district to be reimbursed for select health services provided to Medi-Cal eligible students at school. In order for the district to receive reimbursement for these services, we must obtain your consent to release limited education records to the Department of Health Care Services (DHCS) and to our reimbursement recovery vendor; Paradigm Health Care Services. Your consent, or non-consent. does not affect the services available and provided to your child, and should not impact your Medi-Cal benefits. Records that may be shared include: child's name and date of birth; health-related evaluation, intervention and referral information (for services received at school), all of which are shared securely. *
6. TECHNOLOGY/NETWORK USE GUIDELINES (Facts for Parents: Section K). The "Network Use Guidelines" for San Diego Unified School District is a contract and must be signed by students and parent/guardians before the student is given access to technology, the internet and other San Diego Unified networks. *
Required
7a. Student Signature: By completing sections 1-5 and signing below, I the student, have read, understand and acknowledge the policies and rights outlined above and described in detail in Facts for Parents. Type signature and date. *
7b. Parent Signature: By completing sections 1-5 and signing below, I the parent, have read, understand and acknowledge the policies and rights outlined above and described in detail in Facts for Parents. Type signature and date. *
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