Haven Virtual Academy Application Packet for Online School

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1 Haven Virtual Academy Application Packet for Online School Haven Virtual Academy (HVA) offers a unique learning environment for students who are eager to learn and are self-motivated. The Kansas State Accredited Virtual Program allows students to work from home or other locations and complete their academic requirements. If needed, HVA will provide a laptop computer upon payment of a lease fee. Curriculum Options: OdysseyWare is an almost completely Internet based challenging curriculum for grades Students can access the program anytime and anywhere they have access to the Internet. This provides a great deal of flexibility in learning schedules. K-12 Curriculum offers a challenging program for students in grades K-12. It involves lessons that are online and offline. Materials will be shipped to your home directly from K-12. Family Involvement: We believe that a collaborative relationship between the family and school, along with family participation as a fundamental support system, is essential for student success. Communication between school and family is a top priority in this process. Facilities: HVA s office is located at 5 West Ave C in the Partridge Grade School building, in Partridge, Kansas. Our mailing address is Haven Virtual Academy, PO BOX 98, Partridge, KS, Application Process: Our application process offers us an opportunity to enroll students who fit the profile of our program. We are looking for students who are self-motivated and self-disciplined. Penny Wilt Virtual Program Coordinator Terry Fehrenbach Principal Please complete the entire application packet. The application may be submitted through the mail, by fax ( ), or electronically through For more information please contact Penny Wilt by phone ( ) or at Please keep this first page for reference. Return pages two through nine to the school.

2 Application Process Applications will be accepted through September 10, 2014 ~Early Enrollment is Recommended~ Date of Application: Student Name: Anticipated Grade: ( ) Students will be enrolled as full-time students unless prior arrangements are made by parents and written permission is given by the virtual school. If you are requesting less than full-time enrollment please attach a separate page indicating that request. COMPLETED PAPERWORK CHECKLIST: 1. Completed Application for Admission 2. Signed Request for Release of Records 3. Complete Home Language Survey (p. 8) 4. Complete Student Health Verification (p. 9) 5. Completed Media Release form (p. 9) *The following items will be requested from your child s previous school. You will be responsible for providing them if the school does not. 6. *Copy of Birth Certificate 7. *Copy of Immunization Record or Signed Waiver 8. *Copy of Driver s License (if applicable) 9. *Copy of IEP (if applicable) Please carefully review your documents to be sure you ve included all requested information. An incomplete application will delay the processing of your file. Please return completed application to: or Virtual Program-Admissions Haven Virtual Academy P.O. BOX 98 Partridge, KS

3 Active*Military* Family?* Yes* No* (Please Print) Anticipated** GRADE*PLACEMENT* * Name of Student: Age: Street Address: City: State: Zip Code: Student Skype Contact Name: Student Cell Phone: (if applicable) Mailing Address if different from above: City: State: Zip Code: Date of Birth / / Male Female Ethnicity: Name of Parent(s)/Guardian(s) working with student: (Please Print) Name: Home Phone ( ) Cell Phone ( ) Work Phone ( ) Best Contact # ( ) Parent Curriculum Choices: Undecided (I would like more information.) OdysseyWare (3rd 8th Grade Program, High School Program) K-12 (Ktg 6th Grade Program, Middle and High School Courses) A school laptop is needed. (The non-refundable $100 leasing fee is due August 6th.) A school laptop is not needed. 3

4 Family Information: Include other family members living in the home. Name Relationship Age School attending, if applicable Has the student previously applied for admission or previously attended HVA? yes, school year no Is applicant currently (or has been previously) suspended or expelled from school? yes Explain: (use attached page, if necessary) no Does the student currently have an Individualized Education Plan (IEP) or 504 Plan? yes, in the area of no Please describe any accommodations that may be required in order for the student to fully participate in the virtual program including State Assessment accommodations: CURRENT Grade Level: (If summertime, please list last grade level completed.) Current School: School Information: List all schools attended, starting with most recent. School Name Address Phone and Fax Numbers *** How, or from whom, did you learn about Haven Virtual Academy? *** 4

5 Statement of Education Equality HVA is committed to a policy of educational equality. HVA admits students and conducts all educational programs, and employment practices without regard to disability, race, creed, color, gender, national origin, sex, age, handicap, religion, ancestry, need of special services, and/or any other legally protected classification. Any person having inquiries concerning the school s compliance with regulations implementing Title VII of the Civil Rights Act of 1964, Title IX of the Education Act is directed to contact: HVA, %P.O. Box 98, Partridge, KS Family Educational Rights and Privacy Act (FERPA) Consent Form The Family Educational Rights and Privacy Act (FERPA) gives parents and students over 18 years of age ( eligible students ) certain rights to student s education records. One of those rights is the right to consent to disclosures of personally identifiable information contained in the student s education records. HVA is a designated curriculum provider of OdysseyWare and K-12 Inc. We have found that to best serve the student s education needs, it is necessary to disclose a student s name and address to the following classes of vendors that provide important services related to your student s education. In all cases, these vendors will have agreed to ensure the confidential handling of the student s name and address, and to not use the information for purposes other than that contracted for the student s education needs. Designated vendors include: suppliers of computers and educational materials for purpose of shipping to and from the student s home, Customer Care providers that address needs in OdysseyWare, K-12 Inc., and Rosetta Stone, Internet Service Providers, companies that enter the student information into a computer database for use by school officials, and other contractors and subcontractors that HVA, OdysseyWare, or K-12 identify as necessary to providing education services. To best serve the student, HVA requests the following parental consent to disclose the student s name and address to the specified class of contractors. I hereby agree that my student s name and address be provided to the above identified contractors to ensure HVA can best meet the student s needs. Parent/Guardian Signature: Date: 5

6 Acknowledgement of Expectations Please initial each of the following statements: I understand HVA is a full-time accredited public charter school and my student may not be enrolled in any other public school system without written permission from HVA school administration. I understand it is my responsibility to secure an Internet service provider in my home and to set up a Skype account for the student to use for contacting teachers. The Skype account will be required for all students using OW. I understand student progress is a required part of PA; Approximately 3% of the year s curriculum (6% of the semester s) must be completed each week during the school year to remain in the program. I will accept and follow the guidelines and support of a professional teacher in implementing the program with my student. I accept responsibility to supervise my student in using HVA curriculum, and I understand that I am expected to become knowledgeable about it. I understand if attendance and progress requirements are not met my child can be removed from the virtual program. I understand teachers will communicate regularly through and I am responsible for *checking this daily* for updates, and replying when requested. I understand I must report special circumstances that may impede progress in curriculum to the program coordinator, Mrs. Wilt. I understand I am required to participate in regular conferences as needed with HVA staff. I understand teachers will review progress and consider other factors, including parental input, when making student advancement decisions. I understand my student is required to participate in Kansas State Assessments and audit to remain enrolled at HVA. I understand the $100 computer lease fee must be paid in full for students who wish to lease a laptop, and a leasing form must be signed and returned once the laptop is received. This fee is non-refundable. I understand that I am responsible for all laptop repair charges due to accidents or negligence. This can include damage from dropping, spilling, or not caring for it or the charger properly. When there is an issue, I understand it is my responsibility to notify the program coordinator, Mrs. Wilt, as soon as possible so the computer can be checked. I understand if there is an accident of any kind with the laptop I should not turn it on, not plug it in, or try to use it. I should contact the program coordinator, Mrs. Wilt, before attempting to use it again. Please accept this signed and completed document to enroll my child, into Haven Virtual Academy for the academic year. I have reviewed this information with my child and we understand the completion of this enrollment packet does not guarantee admission into the school. Parent/Guardian Signature: Date: 6

7 Request for Records **Top portion to be completed by parent/guardian and returned to HVA.** I hereby give permission for (Student s current school) to release copies of school records to (Student s full name) USD 312 for the purpose of his/her application to Haven Virtual Academy. Such records include, but are not limited to, course grades, standardized test results, extracurricular activities, conduct reports, and evaluation reports such as psychological/educational evaluations. I understand that all records provided to USD 312 will be maintained on a confidential basis. Parent/Guardian Signature Date Student Signature Date To be completed by USD 312 official- Please send the following items to: HVA, Attention: Virtual Program, P.O. BOX 98, Partridge, KS Phone: Fax: Transcript of student s current and previous grades Student s current and previous attendance and conduct records Results of the student s most recent standardized testing Copy of the student s immunization record, birth certificate, and social security card Copy of student s Individualized Education Plan (IEP) or 504 Plan, if applicable Copy of any other pertinent information To be completed by current or previous school- KIDS 10-digit Identification Number School Official Signature Date School Official Print Title 7

8 HOME LANGUAGE SURVEY Upon enrollment, every student or parent/guardian should be given a Home Language Survey. This survey will be used to determine which students should be tested for English proficiency. If a language other than English is marked for any of the numbers1-4, the student must be assessed for his/her English proficiency to determine whether or not the student needs English to Speakers of Other Languages (ESOL) support services. The assessments approved by Kansas State Department of Education to determine eligibility for ESOL services include: The Language Assessment Scales (LAS)/LAS LINKS/Pre-LAS, the IDEA Proficiency Test (IPT)/Pre- IPT, the Language Proficiency Test Series (LPTS), and the Kansas English Language Proficiency Assessment (KELPA)/KELPA-P. If a student scores below proficient/fluent in any of the language domains: listening, speaking, reading, or writing, s/he is eligible for ESOL services. Student Information: Student s Name: Student s Grade: ( ) Student s Date of Birth: Student s Phone Number: Student s Address: On which date did your child first enroll in school in the USA? Student Language Information: 1. What language did your child first learn to speak/use? English Spanish Other (please specify) 2. What language does your child most often speak/use at home? English Spanish Other (please specify) 3. What language do you most often speak/use with your child? English Spanish Other (please specify) 4. What language do the adults at home most often speak/use? English Spanish Other (please specify) Parent/Guardian Information: In which language do you read/write? English Spanish Other (please specify) Signature of Parent or Guardian: Date: 8

9 Student Health Verification Student Name: During the course of the school year, it may be necessary for your student to be on campus or in a group or individual setting where you may not be present. This could occur at a school meeting and during completion of required Kansas Assessments. To guarantee the safety and well being of your student, please complete the following: 1. Does your student have any allergies? Yes No If yes, please list: 2: Does your student take any medications that may need to be administered by a HVA staff member? Yes No If yes, please list: 3. Does your student have any medical conditions that the staff should be aware of in order to provide a safe learning environment? Yes N0 If yes, please explain: I understand this information will be reviewed and released to staff members (which may include transportation staff) as needed. I understand that school staff will not administer any medication without a parent/guardian signature. Medication must be labeled. Parent/Guardian Signature: Date: Media Release Form USD 312 School Year I, consent to allow my child to be photographed, video taped, and/or have his/her speech recorded for sharing on the Internet. The publication site will never post the child s real name with the child s likeness or voice. I consent to publication of these materials, in whole or in part, without restriction or limitation after broadcast for any educational use. I expressly release HVA and USD 312, its trustees, officers, agents, employees, licensees, and assignees, from any and all claims, including copyright, privacy, and defamation arising out of any broadcast, exhibition, publication, or promotion of these materials. Student name (print full name): Parent signature: 9

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