CAHSEE Class Registration Form - Julian Charter School

JULIAN CHARTER SCHOOL
Test Preparation for Grades 9-12
California High School Exit Exam (CAHSEE)
San Diego County
CAHSEE Class Registration Form
Contact Information
Student Name
Parent Name
Address
City
Student
Number
Phone
Number
Emergency
Phone
Zip Code
E-mail
EF Name
Grade Level
CAHSEE Prep Class: All eleventh and twelfth graders who have not passed one or both portions
of the California High School Exit Examination (CAHSEE) must participate in an intervention course.
Location
Course(s)—Check desired course(s)
San Diego Learning Center
6112 Lorca Drive
San Diego, CA 92115
San Diego CAHSEE Prep (2.5 credits each course)
• English: 10:00 AM - 11:30 AM
• Math: 12:00 PM - 1:30 PM
Calendar (Classes held on 7 consecutive Mondays, excluding Presidents’ Day, February 16, and
Monday of Spring Break Week, March 30.)
First day of class: Monday, February 9 Last day of class: Monday, April 6
All materials and instructional supplies are provided free of charge to JCS high school students.
Required Signatures
I understand that to receive course credit attendance, participation, and work completion are mandatory.
Parent
Signature
Student
Signature
Date
Date
Questions: (951) 892-5297; tcondron@juliancharterschool.org
Sign Up
Now!
9th, 10th, 11th, 12th
Graders
Please complete this registration and the medical authorization form located
on the back of this form and return to Sarah Thornton or bring to the first
class meeting.
Mail—Attn: Sarah Thornton
Fax—Attn: Sarah Thornton
26396 Beckman Court, Suite B (951) 304-3056
Murrieta, CA 92562
sthornton@juliancharterschool.org

JCS Learning Center Medical
Authorization Form
Required Parent Authorization for Student in Site
Classes Sponsored by Julian Charter School
Authorization must be filled out by parent/legal guardian.
Student Name _____________________________________________________ Grade _____________________
Emergency Contact Information (During Hours of Event/Class):
Parent/Guardian Name __________________________________________________________________________
Home Phone _________________________ Work Phone _________________ Cell Phone _________________
List name of alternative person that has permission to pick up your child in the event you can’t be reached.
Name _______________________________ Relationship to Student _____________ Phone _______________
Health of Student:
q Check here if there are no special medical problems for the staff to be aware of and/or medications to administer
during the course of this class.
q Check here if your son or daughter has a special medical problem that the staff needs to be aware of in the event
of an emergency. (This includes special diet, allergies, info. on blood transfusions, etc.) Please describe below:
__________________________________________________________________________________________________________________
q My child has medication that may need to be administered during school.
Name of medication: ________________________________________________________________________
(All prescriptions, except those which must be kept on the student’s person for emergency use, must be kept and
distributed by the staff. Bring the medication to the front office with a physician’s written instructions for
dispensing at first class meeting.)
Consent to Treat: (One of the Two Choices Must Be Initialed) **ex. – MA for Mary Anderson: 1. X MA
INDICATE YOUR CHOICE OF ACTION IN THE EVENT OF ACCIDENT OR EMERGENCY.
1) X_____ In the event of an accident or emergency, I do hereby authorize a representative of the school to make such arrangements as
he/she considers necessary for my child to receive medical/hospital care, including necessary transportation. I further
authorize the physician named below to undertake whatever x-ray examination, anesthetic, medical, surgical treatment and
hospital care considered necessary for my child as he/she considers necessary. In the event that said Physician is not
available, I authorize such care and treatment to be performed by a licensed physician or surgeon. I FULLY UNDERSTAND
THAT I WILL BE RESPONSIBLE FOR ALL COSTS INCURRED BY EMERGENCYTREATMENT SERVICES, INCLUDING
AMBULANCE OR EMERGENCY TRANSPORTATION.
Physician’s Name _________________________________ Phone ______________________________________
Medical Insurance or HMO __________________________ Policy # _____________________________________
2) X _____I do not choose the above statement and desire the following action to be taken. List below.
_____________________________________________________________________________________________
Ed. Code Sec. 35330 states that “All persons making the field trip or excursion shall be deemed to have waived all claims against the school, district or the State
of California for injury, accident, illness, or death occurring or by reason of the field trip or excursion. All parents or guardians of pupils taking out of state field
trips or excursions shall sign a statement waving such claims. My signature on this form shall constitute an informed and knowing waiver as required by law.
Signature of Parent/Guardian __________________________
Date ___________________ DL10/07