SCHOOL COUNSELOR REFERRAL

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1 SCHOOL COUNSELOR REFERRAL Student Name: Student ID: Date of Birth: Age: School No.: Grade Level: No. of Credits: Withdrawal Date: Withdrawal Code: Is student employed? No Yes Where? Requirements for elearning entry: FCAT Reading: Passed Total high school credits: 12.0 Is parent aware of this referral? Yes No Additional notes: Parent/Guardian : Address: Home Phone: Cell/Work Phone: After discussing academic options, I am requesting that this student be considered for enrollment at elearning. A copy of this referral has been given to the student and a copy has been filed in our school records. If the student wishes to pursue enrollment at elearning, I will send the referral to the appropriate elearning program. School Counselor Name: Phone: Date: Signature Revised Distributed by: elearning East & elearning West Page 1

2 APPLICATION TO ATTEND e-learning East e-learning West If possible, I prefer to attend: A.M. session 8:00-12:00 P.M session 12:00-4:00 Name: ID 1 Birth Date: / / Age: Address: Cell: Home: Work: Legal guardian(s): Phone: With whom do you live? Relationship: Last high school: Have you withdrawn? Yes No If yes, date: Reason for withdrawal: Do you have an arrest/offense record? Yes No Date(s): Offense charge(s)? Are you court-ordered to attend school? Yes No Please attach copy of court order Have you ever been expelled from school? Yes No Suspended? Yes No Reason(s) Have you taken courses in any of the following formats: Volusia Virtual (VVS) Yes No Florida Virtual (FLVS) Yes No Apex Yes No If yes, course(s) taken VCS has child care and elective credits available through the Teenage Parent Program: Are you pregnant or a parent? Yes No Due date: Child s date of birth: E-Learning East and West do not provide transportation. Do you have a driver s license? Yes No Has it been suspended for non-school attendance? Yes No How will you travel to school? Page 2

3 Student Applicant Essay This is an opportunity for you to express yourself and for us to learn more about you so we can help you be successful. Please write an essay explaining why you want to enroll in the e-learning program. Include the reasons traditional school has not worked for you and why you think our program will fit your needs. Also, discuss the personal changes you are willing to make to succeed here. Also, tell us who is encouraging you to finish high school and why you want to pursue a high school diploma. To really develop your ideas, please write between three and six paragraphs using complete sentences. Applicant Signature Date Parent/Guardian Signature Date Page 3

4 Name: ID 1 Date e-learning CONTRACT If accepted, I agree to the following: 1. Attend school every day and be on-time 2. Pursue/complete my individual academic goals and complete requirements for high school graduation to receive a diploma from my zoned school. 3. Adhere to all items in the e-learning Student Handbook and Policy Manual, including all Volusia County Schools policies and procedures. COMPUTER LAB CONTRACT If accepted, I agree to the following: 1. Only use the program authorized by your teacher and no other programs. 2. Use the Internet ONLY for the teacher directed course work. 3. Leave personal software or games outside of the classroom. 4. Print only when given permission from the instructor. 5. No food or drinks are allowed in the lab. 6. Become familiar with and adhere to Volusia County Schools Electronic Usage policy. AGREEMENT OF UNDERSTANDING: STUDENT HANDBOOK & POLICY MANUAL 1. I have read, understand and agree to follow the guidelines outlined in the e-learning Student Handbook and Policy Manual. 2. I have read, understand and agree to follow the Volusia County Schools Code of Student Conduct and understand I can access it online at any time. 3. I have read the Volusia County Schools District-wide Dress Code Policy and agree to maintain compliance when I am on the e-learning campus. GRADUATION INFORMATION I understand that it is MY responsibility to make graduation arrangements directly with my zoned school. e- Learning WILL NOT make these arrangements. In addition, I understand that my participation in activities such as Prom and Homecoming is at the discretion and approval of my zoned school. Page 4

5 Student: ID: 1 Grade Date: Dear Parent/Guardian: The School District of Volusia County offers elearning as a school of choice. This program serves students who may benefit from an alternative academic setting. It is designed to increase interest and achievement by providing a blended learning environment, allowing for varying teaching strategies, and classroom structure. This is a voluntary program with a limited enrollment. If your child is eligible to participate in this program, please sign and return to e-learning. Yes, I give my permission for my child to be served in this program. No, I do not give my permission for my child to be served in this program. Parent/Guardian (Student if 18 years or older) Date Page 5

6 The School District of Volusia County Post Office Box 2118 DeLand, Florida CODE OF STUDENT CONDUCT AND DISCIPLINE PARENT AND STUDENT ACKNOWLEDGEMENT This code has been developed to help your son/daughter understand his/her rights and responsibilities. Parents/guardians should take notice of the attendance section of this code. Parent/s guardians should take special notice of those provisions of this code that could lead to your child being suspended or expelled from the School District of Volusia County. The school is in need of your help and cooperation. When you have read and discussed this document with your son/daughter, it is requested that you sign this sheet and return it to the school. This form will be kept in your son s/daughter s cumulative folder. FAILURE TO RETURN THIS ACKNOWLEDGEMENT WILL NOT RELIEVE A STUDENT OR THE PARENT(S) /GUARDIAN(S) OF THE STUDENT FROM RESPONSIBILITY FOR KNOWLEDGE OF THE CONTENTS OF THE CODE AND WILL NOT EXCUSE NON-COMPLIANCE BY THE STUDENT WITH THE PROVISIONS OF THE CODE. SCHOOL BOARD POLICY AS DESCRIBED IN THE CODE PROHIBITS STUDENTS FROM BRINGING ILLEGAL DRUGS AND DANGEROUS WEAPONS AND/OR FROM COMMITTING VIOLENCE AGAINST PERSONS OR PROPERTY ON SCHOOL GROUNDS OR AT SCHOOL SPONSORED FUNCTIONS. PARENTS SHOULD TAKE NOTICE THAT IF THEIR CHILD DISREGARDS THESE RULES AND BRINGS ILLEGAL DRUGS OR DANGEROUS WEAPONS OR COMMITS ACTS OF VIOLENCE AGAINST PERSON OR PROPERTY, THE POTENTIAL CONSEQUENCES COULD INVOLVE EXPULSION OF THE STUDENT FROM THE SCHOOL SYSTEM. I have reviewed and understand the Code of Student Conduct and Discipline and know that it is available on the VCS website for further reading at any time. Student Signature Date Parent/Guardian Signature Date Page 6

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