Enrollment Forms Packet (EFP)

Transcription

1 Chicago Virtual Charter School Enrollment Processing Center 38 S. Peoria Street Chicago, Il Ph Enrollment Forms Packet (EFP) Please review the information below. Based on r student(s) grade and applicable circumstances, are required to submit documentation in order to complete this step in the enrollment process. You will need to bring these documents in person to be reviewed by a CVCS administrator, do not fax or mail these into CVCS and make sure bring originals for review. Our address is below: Chicago Virtual Charter School 38 S. Peoria Street Chicago, Il Office Hours Mon-Fri 8 AM-4PM Required For? Item Description? Required for all Students Required for all 10-11th Grade Students Required for student with an IEP or other Special Education needs Required for students that have a 504 plan Proof of Age Proof of Residency Report Card Immunization Record and Medical Form Early Dismissal Release Authorization Form Health Insurance and Informaiton Form Student Transportation Form Release of Records Home Language Survey Unofficial Transcripts IEP Evaluation Report 504 Accommodation Plan Official Birth Certificate (not the hospital issued certificate) OR Baptismal Records Please sumbit two of the following items: Current utility bill, Illinois driver s license or State of Illinois identification card, deed, employer identification card, MediPlan/Medicaid card, voter registration card, court documents, Illinois Department of Public Aid card, stamped USPS change of address form, Illinois state aid check/social security check, other identification card issued by a federal or state agency or foreign government consulate such as the Matricula Consular. The most recent Report Card, except for students enrolling in Kindergarten. Please have forms filled out by r students physician and submit to CVCS. This form exists so that can authorize certain people to release r child from school. Please note that they will be the only ones which can release r child. Please fill out and submit. To ensure the safety of r child, CVCS requires that confirm how r student will be getting to and from the Learning Center each week. This information will also be on each student s ID card so CVCS staff knows exactly how each student will safely leave the building. By filling out this form, are giving our school permission to request r student s official records from their previous school after the approval process. If r child is enrolling in Kindergarten or was Homeschooled please indicate it on the form, fill out the top portion and sign it. A list of Home Language Codes is also provided to use as a reference guide. You will need to request an unofficial transcript from r student's current school, which will show r student s academic standing. This is required in order to place all 10th and 11th graders. Once r student is approved, we will receive the official transcript. A copy of r student s current IEP (Individualized Education Plan). Because the IEP expires yearly, please submit the current IEP. The Evaluation Report is valid for 3 years. If do not have a copy of r student s ER, can request a copy from r student s current school. A copy of r student s current 504 Accommodation Plan. Because the 504 expires yearly, please submit the current 504. v1.1

2 c/o Merit School of Music 38 South Peoria Street Chicago, Illinois Phone Fax REQUEST FOR STUDENT RECORDS (This section to be filled out by parent): Name of school currently holding student records: School Phone Number: School Fax Number: Street Address: City, State, Zip: (This section to be filled out by CVCS): Dear School Official: Date: The following student has enrolled at Chicago Virtual Charter School for the school year: Name: ID Number: Date of Birth: Please send the following records pertaining to the aforementioned student: Cumulative Records Card Cumulative Folder Medical Folder Individualized Learning Plan (if applicable) Special Education Records (504 or IEP, or School Based Problem Solving file) Please forward records to: Chicago Virtual Charter School or CPS Mail Run/GSR 38 Attn: Freddie Gonzalez Registrar 38 South Peoria Street Chicago, Illinois Should have any questions, please contact Freddie Gonzalez, Registrar, at ext 585. PARENTAL PERMISSION IS NO LONGER REQUIRED WHEN RECORDS ARE REQUESTED BY AUTHORIZED SCHOOL PERSONNEL.

3 c/o Merit School of Music 38 South Peoria Street Chicago, Illinois Phone Fax Student Transportation Form To ensure the safety of r child, CVCS requires that confirm how r student will be getting to and from the Learning Center each week. This information will also be on each student s ID card so CVCS staff knows exactly how each student will safely leave the building. Please complete the form below and turn in to Mr. Gonzalez with r compliancy documents. Thank in advance for r help and cooperation. Learning Coach First Name: Learning Coach Last Name: Student First Name: Student Last Name: Only one box should be checked: Please indicate how r child will be getting to and from the Learning Center each week. Parent/guardian will drop off/pick up student at the side door of the school Student will carpool with a friend/neighbor and will be picked-up at the side door of the school Name of friend/neighbor: Student will be picked up by a friend/neighbor and will wait in the CVCS Parent Room Name of friend/neighbor: Parent/guardian will wait in the CVCS Parent Room Student will be taking public transportation (CTA bus or train)

4 Chicago Virtual Charter School c/o Merit School of Music 38 S Peoria St Chicago, IL Early Dismissal Release Authorization Early Dismissal Release Authorization The following people have r authorization to release r child from school. Please note that they will be the only ones who can release r child. A valid ID must be presented at all times to the office clerk, and they must be 18 years or over. Name:(last) (first) Relationship: Work Phone: ( ) Home Phone: ( ) Cell Phone: ( ) Name:(last) (first) Relationship: Work Phone: ( ) Home Phone: ( ) Cell Phone: ( ) Name:(last) (first) Relationship: Work Phone: ( ) Home Phone: ( ) Cell Phone: ( ) Name:(last) (first) Relationship: Work Phone: ( ) Home Phone: ( ) Cell Phone: ( ) Name:(last) (first) Relationship: Work Phone: ( ) Home Phone: ( ) Cell Phone: ( )

5 Chicago Virtual Charter School c/o Merit School of Music 38 S Peoria St Chicago, IL Health Insurance and Health Information Primary Physician Information: Doctor Name: Doctor Phone: Dentist Name: Dentist Phone: If the student is covered by Medicare, provide the Medicare number: Read and Check: be receiving-including but not limited to: vision and hearing screenings, nursing services, speech therapy, occupational and/or physical therapy-the school district as the right to receive partial reimbursement from Medicare for those services renderedfrom Medicare for those services rendered Please list any serious allergies, conditions, or restrictions the student has: Please list any physical or emotional disabilities the student has: EMERGENCY RELEASE CVCS will attempt to reach the parent/legal guardian or one of the people listed as an emergency contact but if none of these people can be reached, CVCS personnel have my permission to use discretion in securing medical aid in an emergency. IT IS UNDERSTOOD THAT NEITHER CVCS NOR THE PERSON RESPONSIBLE FOR OBTAINING THIS MEDICAL AID WILL BE RESPONSIBLE FOR THE EXPENSE INCURRED. Parent/Guardian Signature: Date:

6 Chicago Public Schools Complete this Home Language Survey at the student s initial enrollment in Chicago Public Schools. (This form must be kept in the student s folder.) School: Room: Unit: Area: Student Name: Student ID No.: English 1. Is a language other than English spoken at home? No Yes (Language) 2. Does the student speak a language other than English? Home Language Code Enter the appropriate language code (from the back of this form) on this line and in to IMPACT. No Yes (Language) Spanish Polish 1. Se habla algún otro lenguaje que no sea ingles en el 1. Czy językiem innym niż angielski mówi się w domu? hogar? No Sí (Lenguaje) Nie Tak (język) 2. Habla el estudiante un lenguaje que no sea el inglés? 2. Czy uczeń mówi innym językiem niż angielski? No Sí (Lenguaje) Nie Tak (język) Chinese Arabic Bosnian/Croatian/Serbian Urdu Office of Language and Cultural Education Revised: Dec 2007 Signature of Parent/Guardian Date Signature of School Official Date Notes: The school staff who enrolls the student is required to obtain answers from the parent/legal guardian If the parent/guardian does nor speak English and the school does not have staff who speaks the parent/guardian s language, identify the language spoken by the parent/guardian through any assistance available in the school (including students). If exact name of the language cannot be determined, enter the code for Other (099) as a temporary entry. The exact language must be determined within two weeks after the enrollment. Assistance from Area Compliance Facilitators is available. If multiple languages are specified in response to either of the two questions, ask the parent/guardian for the language of his/her choice. ***For Language Code Lists, see back.

7 HOME LANGUAGE CODE LIST LIST OF LANGUAGE CODE (Language Sequence) CODE LANGUAGE CODE LANGUAGE CODE LANGUAGE CODE LANGUAGE 001 SPANISH 035 RUSSIAN 072 MENOMINEE 119 KONKANI 002 GREEK 036 CEBUANO (VISAYAN) 073 CAMBODIAN (KHMER) 120 KRIO 003 ITALIAN 037 GUJARATI 074 LAO 121 KURDISH 004 POLISH 038 LATVIAN 075 SHONA 122 LINGALA 005 GERMAN 039 SIOUX (DAKOTA) 076 AFRIKAAN (TAAL) 123 LUGANDA 006 ALGONQUIN 040 NORWEGIAN 077 NEPALI 124 LUYIA (LUHYA) 007 SERBIAN 041 DANISH 078 MARATHI 125 LUNDA 008 KOREAN 042 ALBANIAN, CHEG 079 ONEIDA 126 YOMBE 009 PILIPINO (TAGALOG) (KOSOSVO/MACEDONIA) 080 HAUSAN 127 OKINAWAN 010 ARABIC 043 COMANCHE 082 PIMA 128 ORIYA 011 JAPANESE 044 FINNISH 084 PUEBLO 129 ORRI (ORING) 012 FRENCH 045 SLOVAK 085 IBO 131 PASHTO (PUSHTO) 013 SAMOAN 046 SWAHILI 086 TELUGU (TELEGU) 132 SIKKIMESE 014 HINDI 047 TAIWANESE (FORMOSAN) 087 CHOCTAW 133 SINDHI 015 BURMESE 048 CREEK 088 WINNEBAGO 134 SINHALESE 016 YIDDISH 049 HAITIAN - CREOLE 090 YORUBA 135 SOTHO 017 LITHUANIAN (049 AND 118 COMBINED) 091 MALTESE 137 TIBETAN 018 UKRANIAN 050 CHIPPEWA 093 ROMANY (GYPSY) 139 KACHE (KAJE, JJU) 019 HUNGARIAN 052 EWE 094 TAMIL 142 KPELLE 020 CZECH 053 PANJABI (PUNJABI) 095 HOPI 143 ILONGO (HILIGAYNON) 021 CANTONESE (CHINESE) 055 BULGARIAN 096 SLOVENIAN 144 EFIK 022 THAI 056 APACHE 097 CHEROKEE 146 MIEN (YAO) 023 PORTUGUESE 057 GAELIC (SCOTTISH) 098 CROW 147 CHADCHOW/TEDCHIU 024 SWEDISH 058 MACEDONIAN 102 GAELIC (IRISH) (CHINESE) 025 ASSYRIAN 059 MALAY 103 AKAN (FANTE, ASANTE) 148 FUKIEM/HOKKIEN (SYRIAC, ARAMAIC) 060 MALAYALAM 104 TULUAU (CHINESE) (Old 113) 026 ARMENIAN 061 NAVAJO 105 AMHARIC 149 HAINANESE (CHINESE) 027 ROMANIAN 062 INDONESIAN 107 BALINESE 150 SHANGAHI (CHINESE) 028 DUTCH/FLEMISH 063 KANNADA (KANARESE) 108 CHAMORRO 151 CROATIAN 029 HEBREW 064 ESTONIAN 111 ESKIMO 152 BOSNIAN 030 MANDARIN 065 FLEMISH 113 HAKKA (CHINESE) 153 ALBANIAN, TOSK 031 FARSI (PERSIAN) 066 KASHMIRI 114 WELSH 162 MAAY 032 TURKISH 067 BENGALI 115 GUYANESE 163 KRAHN 033 URDU 068 HIMONG 116 USE 049 (Haitian) 199 MONGOLIAN 034 VIETNAMESE 070 ICELANDIC 118 PAMPANGAN 099 OTHER LIST OF LANGUAGE CODE (Language Sequence) IN ALPHABETICAL ORDER 076 AFRIKAAN (TAAL) 064 ESTONIAN 142 KPELLE 023 PORTUGUESE 103 AKAN (FANTE, ASANTE) 052 EWE 163 KRAHN 084 PUEBLO 042 ALBANIAN, CHEG 031 FARSI (PERSIAN) 120 KRIO 027 ROMANIAN (KOSOSVO/MACEDONIA) 044 FINNISH 121 KURDISH 093 ROMANY (GYPSY) 153 ALBANIAN, TOSK 065 FLEMISH 074 LAO 035 RUSSIAN 006 ALGONQUIN 012 FRENCH 038 LATVIAN 013 SAMOAN 105 AMHARIC 148 FUKIEM/HOKKIEN 122 LINGALA 007 SERBIAN 056 APACHE (CHINESE) (Old 113) 017 LITHUANIAN 150 SHANGAHI (CHINESE) 010 ARABIC 102 GAELIC (IRISH) 123 LUGANDA 075 SHONA 026 ARMENIAN 057 GAELIC (SCOTTISH) 125 LUNDA 132 SIKKIMESE 025 ASSYRIAN 005 GERMAN 124 LUYIA (LUHYA) 133 SINDHI (SYRIAC, ARAMAIC) 002 GREEK 162 MAAY 134 SINHALESE 107 BALINESE 037 GUJARATI 058 MACEDONIAN 039 SIOUX (DAKOTA) 067 BENGALI 115 GUYANESE 059 MALAY 045 SLOVAK 152 BOSNIAN 149 HAINANESE (CHINESE) 060 MALAYALAM 096 SLOVENIAN 055 BULGARIAN 049 HAITIAN - CREOLE 091 MALTESE 135 SOTHO 015 BURMESE (049 AND 118 COMBINED) 030 MANDARIN 001 SPANISH 073 CAMBODIAN (KHMER) 113 HAKKA (CHINESE) 078 MARATHI 046 SWAHILI 021 CANTONESE (CHINESE) 080 HAUSAN 072 MENOMINEE 024 SWEDISH 036 CEBUANO (VISAYAN) 029 HEBREW 146 MIEN (YAO) 047 TAIWANESE/FORMOSAN 108 CHAMORRO 014 HINDI 199 MONGOLIAN 094 TAMIL 147 CHADCHOW/TEDCHIU 068 HIMONG 061 NAVAJO 086 TELUGU (TELEGU) (CHINESE) 095 HOPI 077 NEPALI 022 THAI 097 CHEROKEE 019 HUNGARIAN 040 NORWEGIAN 137 TIBETAN 050 CHIPPEWA 085 IBO 116 USE 049 (Haitian) 104 TULUAU 087 CHOCTAW 070 ICELANDIC 127 OKINAWAN 032 TURKISH 043 COMANCHE 143 ILONGO (HILIGAYNON) 079 ONEIDA 018 UKRANIAN 048 CREEK 062 INDONESIAN 128 ORIYA 033 URDU 151 CROATIAN 003 ITALIAN 129 ORRI (ORING) 034 VIETNAMESE 098 CROW 011 JAPANESE 118 PAMPANGAN 114 WELSH 020 CZECH 139 KACHE (KAJE, JJU) 053 PANJABI (PUNJABI) 088 WINNEBAGO 041 DANISH 063 KANNADA (KANARESE) 131 PASHTO (PUSHTO) 016 YIDDISH 028 DUTCH/FLEMISH 066 KASHMIRI 009 PILIPINO (TAGALOG) 126 YOMBE 144 EFIK 119 KONKANI 082 PIMA 090 YORUBA 111 ESKIMO 008 KOREAN 004 POLISH 099 OTHER Chicago Public Schools Office of Language and Cultural Education

8 Please Print Student s Name STATE OF ILLINOIS DEPARTMENT OF HUMAN SERVICES CERTIFICATE OF CHILD HEALTH EXAMINATION Birth Date Sex School Grade Level /ID# Last First Middle Month/Day/ Year Parent/ Telephone # Address Street City ZIP code Guardian Home Work IMMUNIZATIONS: To be completed by health care provider. Note the mo/da/yr for every dose administered. The day and month is required if cannot determine if the vaccine was given after the minimum interval or age. If a specific vaccine is medically contraindicated, a separate written statement must be attached explaining the medical reason for the contraindication. VACCINE/DOSE Diphtheria, Tetanus and Pertussis (DTP or DTaP) Diphtheria and Tetanus (Pediatric DT or Td) Inactivated Polio (IPV) Oral Polio (OPV) Haemophilus influenzae type b (Hib) Hepatitis B (HB) Varicella (Chickenpox) Combined Measles, Mumps and Rubella (MMR) Measles (Rubeola) Comments Rubella (3-day measles) Mumps Pneumococcal (not required for school entry) PCV7 PPV23 PCV7 PPV23 PCV7 PPV23 PCV7 PPV23 PCV7 PPV23 PCV7 PPV23 Check specific type (PCV7, PPV23) Other (Specify hepatitis A, meningococcal, etc.) Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above immunization history must sign below. Signature Title Date Signature (If adding dates to the above immunization history section, put r initials by date(s) and sign here.) Title Date Signature (If adding dates to the above immunization history section, put r initials by date(s) and sign here.) Title Date ALTERNATIVE PROOF OF IMMUNITY 1. Clinical diagnosis is acceptable if verified by physician. *(All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence.) *MEASLES (Rubeola) MUMPS VARICELLA Physician s Signature 2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official. Person signing below is verifying that the parent/guardian s description of varicella disease history is indicative of past infection and is accepting such history as documentation of disease. Date of Disease Signature Title Date 3. Laboratory confirmation (check one) Measles Mumps Rubella Hepatitis B Varicella Lab Results Date (Attach copy of lab report, if available.) VISION AND HEARING SCREENING DATA Date Age/Grade Vision Hearing IL (R-01-05) Pre-school annually beginning at age 3; School age during school year at required grade levels R L R L R L R L R L R L R L R L R L R L Printed by Authority of the State of Illinois (Complete Both Sides) Code: P = Pass F = Fail U = Unable to test R = Referred G/C = Glasses/ Contacts

9 Student s Name Birth Date Sex School Grade Level/ ID # Last First Middle Month/Day/ Year HEALTH HISTORY TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER ALLERGIES (Food, drug, insect, other) MEDICATION (List all prescribed or taken on a regular basis.) Diagnosis of asthma? Child wakes during the night coughing Yes Yes No No Birth defects? Yes No Developmental delay? Yes No Blood disorders? Hemophilia, Sickle Cell, Other? Explain. Yes No Indicate Severity Loss of function of one of paired organs? (eye/ear/kidney/testicle) Yes No Hospitalizations? When? What for? Yes No Surgery? (List all.) When? What for? Diabetes? Yes No Serious injury or illness? Yes No Head injury/concussion/passed out? Yes No TB skin test positive (past/present)? Yes* No Seizures? What are they like? Yes No TB disease (past or present)? Yes* No Heart problem/shortness of breath? Yes No Tobacco use (type, frequency)? Yes No Heart murmur/high blood pressure? Yes No Alcohol/Drug use? Yes No Dizziness or chest pain with Yes No exercise? Eye/Vision problems? Glasses Contacts Last exam by eye doctor Other concerns? (crossed eye, drooping lids, squinting, difficulty reading) Family history of sudden death before age 50? (Cause?) Yes Yes No No Dental Braces Bridge Plate Other Other concerns? *If yes, refer to local health department. Ear/Hearing problems? Yes No Bone/Joint problem/injury/scoliosis? Yes No Information may be shared with appropriate personnel for health and educational purposes. Parent/Guardian Signature Date Entire section below to be completed by MD/DO/APN/PA (*INDICATES TESTING MANDATED FOR STATE LICENSED CHILD CARE FACILITIES) Yes PHYSICAL EXAMINATION REQUIREMENTS HEIGHT WEIGHT BMI B/P DIABETES SCREENING BMI> 85% age/sex Yes No And any two of the following: Family History Yes No Ethnic Minority Yes No Signs of Insulin Resistance (hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans) Yes No At Risk Yes No LEAD RISK QUESTIONNAI RE* Required for children age 6 months through 6 years enrolled in licensed or public school operated day care, preschool, nursery school and/or kindergarten. Blood Test Indicated? Yes No Blood Test Date Blood Test Result (Blood test required in Chicago and other high risk zip codes.) TB SKIN TEST Recommended only for children in high -risk groups including children who are immunosuppressed due to HIV infection or other conditions, recent immigrants from high prevalence countries, or those exposed to adults in high -risk categories. See CDC guidelines. Date Read / / Result mm LAB TESTS *INDICATES TESTING MANDATED FOR STATE LICENSED CHILD CARE FACILITIES Hemoglobin * or Hematocrit * Date Results Date Results Sickle Cell * (as indicated) Urinalysis Other SYSTEM REVIEW Normal Comments/Follow-up/Needs Normal Comments/Follow-up/Needs Skin Ears Endocrine Gastrointestinal Eyes Normal Yes No Objective screening Yes No Result Genito-Urinary Amblyopia Yes No Referred to Opthalmologist/Optometrist Yes No Neurological LMP Nose Throat Mouth/Dental Cardiovascular/HTN Respiratory NEEDS/MODIFICATIONS required in the school setting Musculoskeletal Spinal examination Nutritional status Mental Health DIETARY Needs/Restrictions SPECIAL INSTRUCTIONS/DEVICES e.g. safety glasses, glass eye, chest protector for arrhythmia, pacemaker, prosthetic device, dental bridge, false teeth, athletic support/cup MENTAL HEALTH/OTHER Is there anything else the school should know about this student? If would like to discuss this student s health with school or school health personnel, check title: Nurse Teacher Counselor Principal EMERGENCY ACTION needed while at school due to child s health condition (e.g., seizures, asthma, insect sting, food, peanut allergy, bleeding problem, diabetes, heart problem)? Yes No If yes, please describe. On the basis of the examination on this day, I approve this child s participation in (If No or Modified,please attach explanation.) PHYSICAL EDUCATION Yes No Modified INTERSCHOLASTIC SPORTS (for one year) Yes No Limited Physician/Advanced Practice Nurse/Physician Assistant performing examination Print Name Signature Date Address Phone (Complete both sides)

10 ENGLISH Race and Ethnicity Survey Student s Name: Gender: Birth Date: School Name: School ID: INSTRUCTIONS: Please answer the questions below. Both questions must be answered. Part A asks about the student's ethnicity and Part B asks about the student's race. If decline to respond to either question, the school district is required to provide the missing information by observer identification. Part A. Is this student Hispanic/Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.) Choose only one. No, not Hispanic/Latino Yes, Hispanic/Latino The question above is about ethnicity, not race. No matter which answer selected, continue and respond to the question below by marking one or more boxes to indicate what consider this student's race to be. Part B. What is the student's race? Choose one or more. American Indian or Alaska Native (A person having origins in any of the original peoples of North and South America, including Central America, and who maintains tribal affiliation or community attachment.) Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.) Black or African American (A person having origins in any of the black racial groups of Africa.) Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.) White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.)