STUDENT S PRINTED NAME

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1 STUDENT S PRINTED NAME Thank you for your interest in Pivot Charter School! To ensure that you provide us with all of the Information we need to begin processing your application, we ask that you refer to this checklist. Student Registration form Caregiver Authorization Affidavit (Required if you are not the legal parent/guardian) Authorization for Release of records form Income Survey Signed No Child Left Behind form Broward Release From Emergency Contact Information List of required documents (Not included in packet; student/ parent must obtain from other sources, including the previous school district.) Proof of guardianship, if you are not the legal parent or guardian. Transcript with year ending grades, progress report, or report card. Proof of Residence-A CURRENT utility bill, rental/mortgage agreement or other proof of residency. Mail or Fax the application and requested documents to our office at: PIVOT CHARTER SCHOOL FT. LAUDERDALE, BROWARD COUNTY 8129 North Pine Island Road Tamarac, FL Phone Number: Fax: PIVOT CHARTER SCHOOL TAMPA, HILLSBOROUGH COUNTY 3020 South Falkenburg Road Riverview, FL Phone Number: Fax: PIVOT CHARTER SCHOOL FT. MYERS, LEE COUNTY 2675 Winkler Ave. Suite 200 Fort Myers, FL Phone Number: Fax:

2 STUDENT REGISTRATION FORM I am applying to (check one): Pivot Ft. Lauderdale Pivot Tampa Pivot Ft. Myers Student Grade School Year for Registration: Date of Enrollment: Student Identification Numbers: SSN: System Number: Student Name: Last, First, M.I.- Date of Birth: Address: Apt.#: City: State Zip: Home Phone: Other Phone: Gender: Male Female Primary Home Language: Racial/Ethnic Category (Please select only one): White/Non-Hispanic Asian Pacific Islander Hispanic Alaskan Native Black/Non-Hispanic American Indian Other if Other, please specify: Student Programs/Tests/Discipline Has the student ever been retained in a grade? NO YES if YES, list the grade(s) Does the student require remedial instruction or tutoring? NO YES if YES, in which subject(s)? Is the student receiving/has the student received Exceptional Student Education services? YES NO If YES, are they currently enrolled in a program and what services do they receive? Is the student receiving/has the student received Free/Reduced school meals? YES NO Has the student ever taken Advanced Placement or Dual Enrollment courses? YES NO Has the student ever taken the PSAT, SAT, or ACT? YES NO If YES, what exam(s)? Exam Score(s)? : Has the student ever been placed on probation, suspended, or expelled from a school? YES NO IF yes, please explain: Current School of Attendance : ADDRESS: City: Grade: State: Zip: School Phone No.: Principal s Name: 1

3 INCOME SURVEY FREE AND REDUCED-PRICED SCHOOL MEALS FAMILY APPLICATION PART 1. ALL HOUSEHOLD MEMBERS Name of all household members (first, Middle Initial,Last) Name of school for each child/or indicate NA if child is not in school Check if a foster child (legal responsibility of welfare agency or court) *if all children listed below are foster children, skip to Part 5 to sign this form. Check if NO Income PART 2. BENEFITS IF ANY MEMBER OF YOUR HOUSEHOLD RECEIVES (STATE SNAP),(FDPIR) or (State TANF Cash Assistance), PROVIDE THE NAME OF CASE NUMBER FOR THE PERSON WHO RECEIVES BENEFITS AND SKIP TO PART 5. IF NO ONE RECEIVES THESE BENEFITS, SKIP TO PART 3. NAME: CASE NUMBER: PART 3. IF ANY CHILD YOU ARE APLYING FOR IS HOMELESS, MIGRANT, OR A RUNAWAY CHECK THE APPROPRIATE BOX AND CALL Deputy Superintendent- (954) HOMELESS MIGRANT RUNAWAY Dawne Gullatt, Ed. S., MSW (813) PART 4. TOTAL HOUSEHOLD GROSS INCOME. You must tell us how much and how often. 1. NAME (LIST ONLY HOUSEHOLD MEMBERS WITH INCOME) 2. GROSS INCOME AND HOW OFTEN IT WAS RECEIVED Earning From Work before deductions Welfare,child Support, alimony Pension, retirement, Social Security, SSI, VA benefits All other Income (EXAMPLE) JANE SMITH $199.99/Weekly $149.99/every other Week $99.99/Monthly $50.00/monthly $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / 2

4 PART 5. SIGNATURE AND LAST FOUR DIGITS OF SOCIAL SECURITY NUMBERS (ADULT MUST SIGN) An adult household member must sign the application. If part 4 is completed, the adult signing the forms also must list the last four digits of his or her Social Security Number or mark the I do not have a Social Security Number box. (See Privacy Act Statement on the back of this page.) I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get federal funds based on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted. Sign here: Print Name: Date: Address: Phone Number: City: State: Zip Code: Last four digits of Social Security Number: ***-**- I do not have a Social Security Number PART 6.CHILDREN S ETHNIC AND RACIAL IDENTITIES (OPTIONAL) Choose one ethnicity: Choose one or more (regardless of ethnicity) Hispanic/Latino Asian American Indian or Alaska Native Black or African American Not Hispanic/Latino White Native Hawaiian or other Pacific Islander DO NOT FILL OUT THIS PART. THIS IS FOR SCHOOL USE ONLY. Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice a Month x 24, Monthly X 12 Total Income: Per: Week, Every 2 Weeks, Twice A Month, Month, Year Household size: Categorical Eligibility: Date Withdrawn: Eligibility: Free Reduced Denied Reason: Temporary: Free Reduced Time Period (expires after days) Determining Official s Signature: Date: Confirming Official s Signature: Date: Verifying Official s Signature: Date: 3

5 Your children may qualify for free or reduced-price meals if your household income falls at or below the limits on this chart. FEDERAL ELIGIBILITY INCOME CHART for School Year Household Size Yearly Monthly Weekly 1 21,590 1, ,101 2, ,612 3, ,123 3, ,634 4, ,145 4,929 1, ,656 5,555 1, ,167 6,181 1,427 Each additional person: 7, Privacy Act Statement: This explains how we will use the information you give us. The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reducedprice meals. You must include the last four digits of the social security number of the adult household member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program, or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if our child is eligible for free or reduce-price meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education, health and nutrition programs to help them evaluate, fund or determine benefit for their programs, auditor for program review, and law enforcement officials to help them look into violations of program rules. Nondiscrimination Statement: This explains what to do if you believe you have been treated unfairly. In accordance with Federal Law and U.S. Department of Agriculture 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 Adjudication, 1400 Independence Avenue, SW, Washington, D.C or call toll free (866) (voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) ; or (800) (Spanish). USDA is an equal opportunity provider and employer. 4

6 STUDENT REGISTRATION FORM PIVOT CHARTER SCHOOL- FLORIDA FAMILY INFORMATION Name of Parent/Guardian: Relationship to Student Parent Guardian Other (specify below) Address: City: State: Zip: Phone Numbers Home: Work: Cell: Address: Name of Parent/Guardian: Relationship to Student Parent Guardian Other (specify below) Address: City: State: Zip: Phone Numbers Home: Work: Cell: Address: Parent and Or Guardians Highest Level of Education Completed HS DIPLOMA/GED TRAINING MILITARY 2 YEAR DEGREE 4 YEAR DEGREE MOTHER FATHER GUARDIAN OTHER Student School Age Siblings Name Age School Name Age School Name Age School 5

7 PIVOT TRANSPORTATION In order to be accommodate the busing needs, please check the appropriate box if your student(s) would like to take advantage of the busing system and include your address. Yes, my student (s) will be using the future busing system. Our address is Street Apt #: City Zip NO, my student(s) will have alternate means of transportation. To accommodate students needing transportation, Pivot Charter School will pay for a student city bus pass through Broward County Transit. YES, my student(s) will need a city bus pass. NO, my student(s) will have alternate transportation. 6

8 CAREGIVER AUTHORIZATION DOCUMENTATION REQUIRED IF YOU ARE NOT THE PARENT OR LEGAL GUARDIAN Instructions: Completion of items 1-4 and the signing of the affidavit are sufficient to authorize enrollment of a minor in school and authorize school-related medical care. Completion of item 5-8 is additionally required to authorize any other medical care. Print Clearly. The minor named below lives in my house and I am 18 years of age or older. 1. Name of Minor 2. Minor s date of birth 3. My name (adult giving authorization) 4. My home address: 5. I am a grandparent, aunt, uncle, or other qualified relative of the minor. 6. Check one or both (for example, if one parent was advised and the other cannot be located): I have advised the parent(s) or other person(s) having legal custody of the minor of my intent to authorize medical care, and have received no objection. I am unable to contact the parent(s) or other person(s) having legal custody of the minor at this time to notify them of my intended authorization. 7. My date of birth: 8. My driver s license or identification card number: Warning: Do not sign this form if any of the statements above are incorrect or you will be committing a crime punishable by a fine, imprisonment, or both. I declare under penalty of perjury under the laws of the State of Florida that the foregoing is true and correct. Printed Name: Signature: Date: PARENT NOTIFICATION No Child Left Behind/Release of Certain Student Information Dear Parent or Guardian: 7

9 Pursuant to the federal No Child Left Behind Act, P.I (Title Ix,sec.9528), Pivot Charter School, must disclose to military recruiters and institutions of higher learning, upon request, the names, addresses, and telephone numbers of high school students. The Pivot Charter School must also notify parents/guardians of their right and the right of the student to request that the district not release such information without prior written consent. Parent/Guardian wishing to exercise their option to withhold their consent to the release of their student s information to the military recruiters and institutions of higher learning must sign the form below and return to Pivot Charter School. If you do not return this form, Pivot Charter School, will consider this affirmation that you consent to your student s directory information being released if requested by military and/or institution of higher learning. Reservation of Consent for the Release of Certain Student Information Under the No Child Left Behind Act Please do not release to military recruiters and / or institutions of higher learning, the name, address, and telephone number of: Student Name (please print): Student Grade: Parent/Guardian s Signature: Date: 8

10 AUTHORIZATION FOR THE RELEASE OF RECORDS Cumulative Records/Transcript Request/ Special Education Records In accordance with the Family Educational Rights and Privacy Act of 1974 and Florida State Law, please release to the school named below all records, including: Cumulative and or Permanent Academic/Health Records Transcripts of Completed Work including Grades to Date Scores and Related ELL information Any Other Educational Information Immunization Records Test Scores IEP/504 Records NOTE: A separate request from our special education department will follow this request, if applicable. To be completed by the parent/guardian: Student Name: Birth Date: Grade: Parent/Guardian Signature: Name of Last School Attended: Address of Last School Attended: City: State: Zip: Dates Attended: Receiving Registrar: Please complete the following in response to education records, sign, date and return by mail. We do not have the records you have requested in our files We have not been able to locate the requested files but our records indicate this student did receive special education services. After reviewing or records, it is determined that the above named student has not received special education services nor has been identified as being eligible for special education services. Please check the appropriate box(s): Expulsion Dates: from to Expulsion Pending E.C. # Advise Teacher Regarding Violent Pupil I.E.P 504 Student is/has been recently suspended * REGISTRAR-PLEASE FORWARD THE STUDENT CUMULATIVE RECORDS TO: PIVOT CHARTER SCHOOL-FT.LAUDERDALE 8129 N. PINE ISLAND ROAD TAMARAC, FLORIDA MAIN:(954) FAX:(954) PIVOT CHARTER SCHOOL-FT.MYERS 2675 WINKLER AVE., SUITE 200 FORT MYERS, FL MAIN:(239) FAX:(239) PIVOT CHARTER SCHOOL-TAMPA 3020 SOUTH FALKENBURG RD. RIVERVIEW, FL MAIN: (813) FAX: (813)

11 EMERGENCY CONTACT INFORMATION Student Name: Please complete all information requested below. In case of Emergency the first contact attempt will be the parent/guardian. If the parent/guardian cannot be reached, we will attempt to contact the additional names listed below. Contact Name Relationship to student Phone Number (s) Contact Name Relationship to student Phone Number (s) Contact Name Relationship to student Phone Number (s) Physician Name Phone Number Physician Name Phone Number Allergies and Medical Issues Epileptic Diabetic Type 1 Diabetic Type 2 Nut Allergy Bee/Wasp Stings Heart Condition Allergies Others Parent/Guardian s Signature: Date: 10

12 PIVOT CHARTER SCHOOL CONTACT INFORMATION Student Name: Date of Birth: Grade Level: Current School: Parent/Guardian Information: Name: Phone #: Relationship to student: Address: City: Zip: 11

13 NOTE: THIS PAGE IS ONLY REQUIRED FOR APPLICATION TO PIVOT FT. LAUDERDALE. GENERAL CHARTER SCHOOL RELEASE FORM THE SCHOOL DISTRICT OF BROWARD COUNTY I understand that I am registering my child in for the (Name of Charter School) school year and he/she will lose the seat in (Name of current assigned school) As of today,. Date Print Name of Student as listed on Student Registration Form (one student per form) Student s District ID#: Student s Birth Date If you wish to change your child s placement, you must go to the Student Assignment Office. Your child will be assigned to a school that has an opening at the time of application. Signature of Parent/Guardian Completing Student Registration Form Date 12

9. WILL THE INFORMATION I GIVE BE CHECKED? Yes and we may also ask you to send written proof.

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