Enrollment Application Inventory

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1 1 of 9 Welcome Prospective Renaissance Academy Parent/Guardian: Thank you for your interest in Renaissance Academy! We are pleased that you have made the active choice to pursue a world-class education for your student. Complete one application for each child you wish to place in the lottery for the school year. The Charter School does not discriminate on the basis of race, color, religion, national or ethnic origin, disability, or sex in admissions, hiring and operations. If you have questions regarding any steps in the enrollment process, please contact me. Please allow two weeks to receive written notification of processed application. Naomi Siedlecki Enrollment/Recruitment Coordinator x Enrollment Application Inventory Please be sure to use the following checklist when submitting your enrollment application. We cannot begin processing your application until we receive the following items: Please submit the following items: Enrollment Application Inventory Form (page 1 of 9--this page) Student Enrollment Application (page 2-3 of 9) Charter School Student Enrollment Notification Form (pages 4-5 of 9) Affidavit/Safe Schools Form (page 6 of 9) Authorization for Request of School Records (page 7 of 9) Home Language Survey (page 8 of 9) Emergency Contact Update Form (page 9 of 9) A Copy of Your Child s Birth Certificate (state issued) Copy of Proof of Residency (utility bill (electric/water), deed, lease, driver s license, property tax bill) A Copy of Your Child s Immunization Record A Copy of Your Child s Most Recent Report Card (1st-8th Grade Students) A Copy of Your Child s Transcript (9th, 10th, 11th & 12th Grade high school students only) A Copy of Your Child s Most Recent Standardized Test Scores (if applicable) A Copy of Your Child s Discipline Report A Copy of Your Child s Most Recent IEP and/or 504 Service Agreement (if applicable) Confirmation from the Parent/Guardian: Student Name: Parent/Guardian Signature: Date: 1 of 9

2 Student Enrollment Application of 9 STUDENT INFORMATION Student s Full Name: Student s Birthdate: Gender: (Include middle name) (MM/DD/YYYY) / / PLEASE PRINT Street Address: City PA, Zip Code Mailing Address: (if different than street address) City PA, Zip Code Home Phone Number: School District of Residence Current School: Current Grade Level: (if applicable) (if applicable) Name of school your child would attend if they did not attend RA in the coming school year: (example: Oaks Elementary, Stewart Middle School, Phoenixville High School) My child will be in grade in FAMILY INFORMATION (Applying) Student Lives With (please list names of adults and relation to student) Parent/Guardian 1 Relation to Student Work Phone Number Cell Phone Number address parent/guardian 1 Parent/Guardian 2 Relation to Student Work Phone Number Cell Phone Number address parent/guardian 2 Are any siblings currently attending Renaissance Academy? YES NO Names of siblings attending: Are there any siblings that do not attend Renaissance Academy that you have applied for the School Year? YES NO Names of siblings and grade for which they applied : CUSTODY INFORMATION Are there special Custodial Court Instructions regarding this child? YES* NO (*If yes, please provide RA with a copy of this court order.) Continue on back of page 2 of 9

3 Page 3 of 9 STUDENT EDUCATIONAL SERVICES Has your child ever participated in ELL support services? YES NO Is your child currently receiving Title I support services? YES NO Does your child currently have a 504 Service Agreement? YES NO Does your child have an Individualized Education Plan (IEP) for any of the following needs? Learning Support Speech Physical Therapy Occupational Therapy Early Intervention Social/Emotional Support Autistic Support Other, please specify: STUDENT RACE/ETHNICITY DATA (for PA Department of Education Reporting Purposes) Are you Hispanic/Latino? (check ONE) YES NO Are you from one or more of these races? (check ALL that apply): American Indian/Alaskan Native Asian Black or African American Native Hawaiian or Pacific Islander White Which race/ethnicity do you consider yourself? (check ONE only): American Indian/Alaskan Native Asian/Pacific Islander Black, not Hispanic Hispanic White, not Hispanic Multi racial/ethnic Have you previously attended a Renaissance Academy Open House or Toured the School? YES NO If you have not previously toured we encourage you to come to one of our Open House events. See Enrollment Page at for upcoming dates and to RSVP. Please tell us how you heard about Renaissance Academy? Word of Mouth Internet Search Print Ad (circle): Times Herald Mercury County Lines Community Newsletter Online Ad (site) Special event (First Friday, Haunted House, Reading Phillies, Dogwood Festival, etc.) Current RA Family/Staff Member (name) What attracted you to Renaissance Academy? What do you hope your child(ren) will gain by coming to Renaissance Academy? By Signing this enrollment form, I affirm the following: I am the parent or legal guardian of this student. All information presented here is accurate and truthful. Parent/Guardian Signature: Date: PLEASE NOTE: In order to begin processing your applications, all forms must be filled out in their entirety and submitted with the requested information. Complete: Charter School Notification, Affidavit/Safe Schools, Authorization for Request of School Records, Home Language Survey, Emergency Contact Form. Submit: Birth Certificate, Proof of Residency, Copy of Student s Immunization Record, Most Recent Report Card, Transcripts (9th -12 th Grade), Most Recent Standardized Test Scores (if applicable), Copy of Discipline Report, and Copy of your child s most recent IEP and/or 504 Service Agreement (if applicable). Renaissance Academy Charter School --- Building Lifelong Learners Page 3 of 9

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6 6 of 9 Affidavit/Safe Schools Form Student s Name: Grade Level: The Safe Schools section of the Pennsylvania School Code state that the parents, guardian, or other person having control over or charge of a student shall, upon registration, provide a sworn statement or affirmation regarding the student s prior discipline record relative to weapons, alcohol, drugs, the willful infliction of injury to another person or any act of violence committed on school property. By checking next to a statement, you are affirming that the statement is accurate for the child listed above. Please check all that apply. I, the undersigned, attest that I AM the parent/guardian or have legal custody of the child listed above. The child listed above HAS NOT been suspended or expelled from any public, charter, independent, private or parochial school for an act or offense involving weapons committed on school premises during a school-sponsored activity, or on any public or private conveyance providing transportation to/from school or school sponsored activity. The child listed above HAS NOT been suspended or expelled from any public, charter, independent, private or parochial school for an act or offense involving alcohol and/or drugs committed on school premises, during a school-sponsored activity, or on any public or private conveyance providing transportation to/from school or school sponsored activity. The child listed above HAS NOT been suspended or expelled from any public, charter, independent, private or parochial school for an act or offense involving the willful infliction of injury to another person committed on the school premises, during a school-sponsored activity, or on any public or private conveyance providing transportation to/from school or school sponsored activity. The child listed above HAS NOT been suspended or expelled from any public, charter, independent, private or parochial school for an act or offense involving any act of violence against person(s) and/or property committed on school premises, during a school-sponsored activity, or on any public or private conveyance providing transportation to/from school or school sponsored activity. Renaissance Academy will be requesting your child s disciplinary records, along with their academic records, from his/her previous school. A willful false statement of the above affirmation is a misdemeanor of the third degree and shall immediately be reported to the appropriate authorities. Parent/Guardian Signature: Date: 6 of 9

7 7 of 9 Authorization For Request of School Records I authorize Renaissance Academy to receive the school records for my son/daughter. (Signature of Parent/Guardian) (Date) Name of Student: Grade PLEASE PRINT Date of Birth: Child s Current School: School s Address: (Street) (City) (State) (Zip Code) School s Fax Number: Please send a copy of his/her: Academic Records Health Records Discipline Records Standardized Test Scores Most Recent or Final Report Card Current Grades (if enrollment date is during the school year) Current Course Schedule (MS/HS only) If applicable, all Confidential Records, including MDT, MER, NOREP, IEP, ELL, Psychological Evaluation, and Speech and Language IEP, 504 Service Agreement. Please forward all records to the attention of: Naomi Siedlecki Enrollment/Recruitment Coordinator x (fax) Office Use Only: This student will be attending Renaissance Academy on: / / Record Request Sent on: / / Records Received on: / / 7 of 9

8 8 of 9 Renaissance Academy Charter School Home Language Survey The Office of Civil Rights (OCR) requires that school districts/charter schools/full day AVTS identify limited English proficient (LEP) students in order to provide appropriate language instructional programs for them. Pennsylvania has selected the Home Language Survey as the method for the identification. School District: Renaissance Academy Date: School: Renaissance Academy Student s Name: Grade: 1. What is/was student s first language? 2. Does the student speak a language(s) other than English? (Do not include languages learned in school.) Yes No If yes, specify the language(s): 3. What language(s) is/are spoken in your home? 4. Has the student attended any United States school in any 3 years during his/her lifetime? Yes No If yes, compelte the following: Name of School State Dates Attended Person completing this form (if other than parent/guardian): Parent/Guardian signature: *The school district/charter school/full day AVTS has the responsibility under the federal law to serve students who are limited English proficient and need English instructional services. Given this responsibility, the school, district/charter school/full day AVTS has the right to ask for the information it needs to identify English Language Learners (ELLs). As part of the responsibility to locate and identify ELLs, the school district/charter school/full day AVTS may conduct screening or ask for related information about students who are already enrolled in the school 8 of 9

9 9 of 9 EMERGENCY CONTACT UPDATE Gina Guarino Buli, CEO Ms. Michelle Boyd, Upper School Principal Ms. Kristie Hawk, Lower School Principal Student Information: Last Name First Name Middle Initial Gender: Male Female Date of Birth: / / Social Security Number: - - Grade: Homeroom Teacher: Siblings at RA? Yes No Primary Phone Number: ( ) - Grade(s) Mailing Address City Zip Residence Address (if different) Parent Information: Please list information that is not included above PARENT/GUARDIAN #1 PARENT/GUARDIAN #2 Last Name First Name Relationship to Student Telephone (if different) Work Number Cell Number Address (if different) Last Name First Name Relationship to Student Telephone (if different) Work Number Cell Number Address (if different) Please list two local people OTHER THAN PARENTS that you would allow to pick up your child should there be a need. First Emergency Contact: Relationship Phone Cell Work Address Second Emergency Contact: Relationship Phone Cell Work Address Signature: Date: 9 of 9

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