Odyssey Academy Beverly Hills. New Student Enrollment Packet Check List

Transcription

1 Odyssey Academy Beverly Hills New Student Enrollment Packet Check List All NEW AEA students must submit the following completed forms: Enrollment Information Special Services Questionnaire Request for Student Records Emergency Contact Form Health Information Form Photo/Videotape Release Community Service Agreement Medication Authorization Form (if applicable) Additional items to be submitted with completed Enrollment Packet: Copy of Student Birth Certificate Proof of Residency (copy of property tax statement or copies of 2 different utility bills) Additional Forms for KINDERGARTEN & 1st GRADE students only: Health Examination - to be completed by physician Updated Immunization Records Oral Health Assessment - to be completed by dentist PLEASE MAIL COMPLETED ENROLLMENT PACKET TO: Albert Einstein Academy Attention: Odyssey Academy BH Admissions Orchard Village Road Valencia, CA 91355

2 ODYSSEY ACADEMY BEVERLY HILLS ENROLLMENT INFORMATION: SCHOOL YEAR STUDENT INFORMATION LEGAL NAME (LAST, FIRST, MIDDLE) GENDER (MALE/FEMALE) STREET ADDRESS CITY ZIP CODE HOME PHONE NUMBER + AREA CODE STUDENT LIVES WITH: MOTHER FATHER BOTH OTHER In a Single Family Permanent Residence (house, apt, condo, mobile home ) In a shelter or transitional housing program In a motel/hotel In a Licensed Child Institution PREVIOUS SCHOOL & DISTRICT OF RESIDENCE ( ) ADDRESS FOR ALL CORRESPONDENCE Doubled up (sharing housing with another family) In a foster home Unsheltered (car/campsite) Other (Please specify) NAME/GRADE OF SIBLINGS ATTENDING AEA SCHOOLS ENTERING WHAT GRADE (Fall 2015) Circle: K DATE OF BIRTH (MM/DD/YY) PLACE OF BIRTH (CITY, STATE, COUNTRY) NAME/GRADE OF SIBLINGS ON WAIT LIST DATE FIRST ENTERED IN A U.S. SCHOOL: / / DATE FIRST ENTERED IN A CA SCHOOL: / / PARENT / LEGAL GUARDIAN (1) NAME (LAST, FIRST, MIDDLE) RELATIONSHIP TO STUDENT STREET ADDRESS CITY ZIP CODE HOME PHONE NUMBER + AREA CODE WORK PHONE NUMBER + AREA CODE CELL PHONE + AREA CODE ADDRESS PARENT/ LEGAL GUARDIAN (2) NAME (LAST, FIRST, MIDDLE) Highest Education Level Completed Not a high school graduate Some college Graduate School/Post Grad High School Graduate College Graduate Decline to State RELATIONSHIP TO STUDENT STREET ADDRESS CITY ZIP CODE HOME PHONE NUMBER + AREA CODE WORK PHONE NUMBER + AREA CODE CELL PHONE + AREA CODE ADDRESS Highest Education Level Completed Not a high school graduate Some college Graduate School/Post Grad High School Graduate College Graduate Decline to State

3 INFORMATION FOR STATISTICAL USE ONLY Is this student Hispanic or Latino? No, not Hispanic or Latino Yes, Hispanic or Latino No matter what you selected above, please continue to answer the following by marking one or more boxes to indicate what you consider the student's race to be. American Ind./Alaskan Native Guamanian Other Asian Asian Indian Hawaiian Other Pacific Islander HOME LANGUAGE SURVEY (Choose language from list below) Black or African American Hmong Samoan Cambodian Japanese Tahitian *What language did this student learn when he or she first began to talk? *What language does your child most frequently use at home? *Name the language most often spoken by the adults at home. *What language do you use most frequently to speak to your child? *If other than English, your child will be individually assessed for English Language Proficiency Chinese Korean Vietnamese Filipino Laotian White/Caucasian Albanian Arabic Armenian Amer. Sign Lang. Assyrian Bengali Burmese Cantonese Cebuano (Visayan) Chaldean Chamorro (Guamanian) Chaozhou (Chiuchow) Dutch Farsi Filipino (Tagalog) French German Greek Gujarati Hebrew Hindi Hmong Hungarian Ilocano Indonesian Italian Japanese Khmer Lao Mandarin (Putonghua) (Cambodian) Khmu Kurdish (Kurdi, Kurmanji) Korean Marshallese Mien (Yao) Mixteco Pashto Polish Portuguese Pujabi Rumanian Russian Samoan Serbo-Croatian Somali Spanish Taiwanese Thai Tigrinya Toishanese Tongan Turkish Ukranian Urdu Vietnamese THE ACADEMY WILL BE NON-SECTARIAN IN ITS ADMISSIONS, PROGRAMS, POLICIES, EMPLOYMENT PRACTICES, AND ALL OTHER OPERATIONS, SHALL NOT CHARGE TUITION, AND SHALL NOT DISCRIMINATE AGAINST ANY STUDENT OR STAFF MEMBER ON THE BASIS OF RACE, ETHNICITY, NATIONAL ORIGIN, OR DISABILITY. Lanu PARENT / GUARDIAN SIGNATURE I/WE HAVE REVIEWED THE INFORMATION AND TO THE BEST OF MY/OUR KNOWLEDGE, THE INFORMATION THAT HAS BEEN PROVIDED IS TRUE AND COMPLETE. I UNDERSTAND THAT GIVING FALSE OR INCOMPLETE INFORMATION REQUESTED HEREIN WILL RISK OR DELAY IN THE PROCESSING OF THE ABOVE-NAMED STUDENT'S ENROLLMENT AND MAY JEOPARDIZE ENROLLMENT AT ANYTIME AT THE ALBERT EINSTEIN ACADEMY. NAME OF PARENT / GUARDIAN (PRINTED): RELATIONSHIP TO STUDENT: SIGNATURE OF PARENT / GUARDIAN: DATE

4 Odyssey Academy Beverly Hills Special Services Questionnaire In order to provide continuity in the educational environment, it is important that the school be informed of any Special Education or 504 services received by your child in the past year. A. Student s Name: Grade in Fall 2015: B. Does your child receive any educational services or assistance and/or has your child been diagnosed with a learning disability? (Complete Sections C & D) D only) C. If yes, please explain. Please list any medications prescribed for your child relating to his/her current special needs. What type of Special Education services or testing has your child received? How long have these services been provided? ***If your child has a current IEP (Individual Education Plan) or a 504 Plan, please list the name of the district, the district contact, and their phone number. Please also attach a copy of the IEP or 504 Plan.*** District Name: District Contact: Phone: Ext. # Please provide us with any additional comments/information that will help us support your child. D. Signature Of Parent Or Legal Guardian Date Preferred Phone Number Please Print Name Of Above Signer Relationship To Student

5 Odyssey Academy Beverly Hills Parent/Guardian: Please complete and sign. Request for Student Records Student Name: Last Name First Name Middle Name Current Grade: Date of Birth: Current School: School Address: I hereby authorize the school listed above to release school records on file for the above named student to Albert Einstein Academy Odyssey Academy Beverly Hills. I understand that my student will be withdrawn from their current school. Parent/Guardian: Relationship (Print Name) Parent/Guardian: Date (Signature) To the Current School: The student above is registering at AEA Odyssey Academy Beverly Hills. To aid our enrollment process, please send us the following information for the student: All report cards/progress reports Results of all standardized tests and evaluations Results of all cognitive abilities tests and evaluations Results of all criterion-referenced tests and evaluations Current health card All Student Study Team (SST) evaluations and recommendations All Special Education Records, including evaluations and IEP materials. Please send this information (including this form) to the address listed below. Kindly contact Admissions at beverlyhills@ealas.org with any questions. Thank you. AEA Odyssey Academy Beverly Hills Attention: Admissions 8844 Burton Way Beverly Hills, CA 90211

6 Odyssey Academy Beverly Hills Emergency Contact & Medical Authorization Student s Last Name First Name Grade in Student s Home Address (Street) (City) (Zip) Student s Home Phone Student s Birthdate Parent/Guardian 1 Name Relationship (Mother, Father, etc...) Daytime Phone Parent/Guardian 2 Name Relationship (Mother, Father, etc...) Daytime Phone Please List Three Emergency Contacts: Emergency Contact Name Relationship To Student Daytime Phone Emergency Contact Name Relationship To Student Daytime Phone Emergency Contact Name Relationship To Student Daytime Phone I hereby GIVE consent for the following medical care providers and hospitals to be called: Physician s Name Phone Dentist s Name Phone Medical Specialist s Name Specialty Phone History Please list any important facts about the child s medical history that may require special attention by school personnel, including allergies, medications being taken, and any physical impairment to which a physician should be alerted. In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by above named doctors, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible. This authorization does NOT cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery. Parent/Guardian Name (printed) Signature of Parent/Guardian Date

7 Health Information Form Student s Name Last First Middle Student s date of birth / / Gender State and Country of Birth Student s address City State Zip Name of Legal Guardian #1 Phone Work/Cell Address Name of Legal Guardian #2 Phone Work/Cell Address Emergency Contact Phone Work/Cell Address Pediatrician/Primary Care Doctor Phone Date of last appointment Specialist Phone Date of last appointment Dentist Phone Date of last appointment Condition Yes Comment Condition Yes Comment Allergies *Please indicate mild, moderate, or severe in the comments section Diabetes Asthma or breathing problems *Please indicate mild, moderate, or severe in the comments section Attention-Deficit/Hyperactivity Disorder Head Injury; concussion Hearing problems or deafness Behavioral problems Cancer Developmental problems Bladder problems Bleeding problems Bowel problems Cerebral Palsy Cystic Fibrosis Dental problems Heart problems Muscle problems Seizures Sickle Cell Disease Speech problems Spinal Injury Surgery Vision problems Other Describe any other health-related information about your child (for example, feeding tube, hospitalizations, hearing aids, assistive devices, braces) List all prescription, over-the-counter, and herbal medications your child takes regularly Is medication required during school hours? Yes No If Yes, medication name and reason for taking Check here if you want to discuss confidential health information with the school nurse or other school authority Yes No Yes No Consent to contact doctor: The school nurse has permission to contact my child s doctor if medically necessary. I understand that the school needs to be informed of any health or medical conditions that may affect my child s school day or impact their learning. I also understand that the school nurse may need to share information about my child s condition with appropriate school staff. If I do not wish that information shared I must request this in writing and file it with the school nurse. Parent/Guardian Signature Parent/Guardian Name (printed) Date

8 Odyssey Academy Beverly Hills Photo/Videotape Release Throughout the school year, there may be times when the Albert Einstein Academy staff, the media, or other organizations, with the approval of the school principal, may take photographs of students, audiotape/videotape students, or interview students for school-related stories in a way that would individually identify a specific student. Those photographs and/or audio/videotaped images or interviews may appear in school or district publications; in school or district video productions; on the school or district website; in the news media; or in other nonprofit, education-related organizations publications. I hereby grant Albert Einstein Academy permission to use my child s photograph and/or videotaped image for the purposes mentioned above. I understand and agree that Albert Einstein Academy may use these photos and/or videotaped images in subsequent school years unless I revoke this authorization by notifying the school principal in writing. I further grant Albert Einstein Academy permission to allow my child to be photographed, audio/videotaped, or interviewed by the news media or other organizations for school-related stories or articles. Please check one: Yes, permission granted No, permission is not granted Student s Name Student s Grade ( ) Parent/Guardian s Signature

9 Odyssey Academy Beverly Hills Community Service Requirements COMMUNITY SERVICE PROGRAM For each year enrolled at AEA Odyssey Academy, students must complete a minimum of 10 hours of community service. Working together, students learn to solve problems, make decisions, and successfully contribute to their community. They connect local concerns with global issues and gain an awareness of others. All this will serve them now and years later as they transition out of school and into the adult world. Community Service Program Purpose: Help students become more active members of their community Increase student knowledge and understanding of their community Meet real community needs Foster relationships between the school and surrounding communities Encourage student altruism and caring for others Improve student personal and social development Teach critical thinking and problem solving skills Increase career awareness and exposure among students Improve student participation in attitudes toward school Improve student achievement in core academic courses Reduce student involvement in risk behaviors Global awareness Community Service Guidelines: Throughout the year, opportunities to perform community service will identified and made available. A pre-approved list of organizations where students can volunteer is available on the school's website. Students can also identify their own community service organizations and receive credit, with prior approval. Examples of community service are: participating in charity walks, community beautification, assisting at a food pantry or homeless shelter, collecting needed items for local charities, forming a litter patrol or recycling program on campus, visiting senior living facilities and making centerpieces, holiday cards or placemats. Classrooms may also create community service projects, but it is up to the student to seek out opportunities and complete their hours. Community Service Forms must be turned in with an authorized signature and Student Reflection to receive credit. Community Service Activity Forms, Prior Approval Forms and procedures for submitting hours can be downloaded from the school's website. Please keep a copy for your records. Forms not filled out completely will not be accepted. An authorized signature from a supervisor on duty is required. I have read the above information and agree to the requirements. Parent/Guardian Signature Date

10 MEDICATION AUTHORIZATION FORM Dear Parent/Guardian, If a student must take medication he/she should do this at home whenever possible. In the event a student must take medication at school, proper written consent must be given to school personnel to administer the medication. Please note the following: No medication including prescription, over-the-counter, or herbal remedies will be administered by school personnel or its agents until the consent forms are completed and on file with the school. All medication must be in the original container. All prescription medication must have a pharmacy label including the student s name, correct dosage, and time(s) to be given. Parents are responsible for bringing medication to the school and picking up unused medication within 10 days after the medication has been discontinued. Students are not allowed to transport their own medication. It must be brought to school by the parent or guardian. School personnel may not cut tablets. If your child needs to receive half a tablet cut the tablets at home or have the pills cut at the pharmacy filling the prescription. Please notify the school immediately, verbally and in writing, if there are any changes to your child s prescription. The school may refuse to administer, or allow to be administered, any medication, which, based on her/his assessment or judgment, has the potential to be harmful, dangerous or inappropriate. In these cases, the school shall notify the parent/guardian and licensed prescriber and explain the reason for refusal. Please take the form on the next page to your child s pediatrician to be completed. Each medication requires a separate form. Bring the medication authorization form and the medication to our collection day that will occur the week before the start of school. The collection date and location will be announced this summer. If you have any questions, concerns, or need information about medication administration at school, please feel free to contact our school nurse at beverlyhills@ealas.org.

11 MEDICATION AUTHORIZATION FORM Note: Each medication requires a separate form. Parents complete this section: Student Name Birthdate Grade Parent/ Guardian 1 Address Home Phone Cell Phone Parent/Guardian 2 Address Home Phone Cell Phone Physician Name Physician Number: I hereby give permission for personnel designated by the principal to give this medication to my child according to the directions stated. I also authorize school personnel designated in medication administration to contact my child s practitioner or myself if there is a question regarding medication administration. I agree to notify the school when the drug is to be discontinued and/or the dosage or time changed. I understand that if the medication is resumed, a new medication authorization form is required. I understand that any unused medication will be properly disposed of within 10 days if not claimed after discontinuation of the medication. (Parent or Guardian Signature) Date Physician completes this section for prescription and OTC medication: Diagnosis/Reason for medication Medication Dose Route/Mode of administration Frequency Times to be given Start date End date Duration (not to exceed current school year) Special instructions for administration Potential adverse reactions I acknowledge with my signature on this document that I will assist and advise designated school personnel with regard to the administration of medication described above, which includes accepting direct communication. I further acknowledge that all instructions should be stated in language of the layperson. Practitioner Signature Date Practitioner Name Phone Number Please place address stamp here:

12 State of California Health and Human Services Agency Primary Care and Family Health Division REPORT OF HEALTH EXAMINATION FOR SCHOOL ENTRY Department of Health Services Children s Medical Services Branch Child Health and Disability Prevention (CHDP) Program To protect the health of children, California law requires a health examination on school entry. Please have this report filled out by a health examiner and return it to the school. The school will keep and maintain it as confidential information. PART I TO BE FILLED OUT BY A PARENT OR GUARDIAN CHILD S NAME Last First Middle BIRTHDATE Month/Day/Year ADDRESS Number/Street City ZIP Code SCHOOL PART II TO BE FILLED OUT BY HEALTH EXAMINER HEALTH EXAMINATION NOTE: All tests and evaluations except the blood lead test must be done after the child is 4 years and 3 months of age. IMMUNIZATION RECORD Note to Examiner: Please give the family a completed or updated yellow California Immunization Record. Note to School: Please record immunization dates on the blue California School Immunization Record (PM 286). REQUIRED TESTS/EVALUATIONS Health History Physical Examination Dental Assessment Nutritional Assessment Developmental Assessment Vision Screening Audiometric (hearing) Screening Tuberculin Test (Mantoux/PPD) Blood Test (for anemia) Urine Test Blood Lead Test Other DATE POLIO (OPV or IPV) DATE EACH DOSE WAS GIVEN VACCINE First Second Third Fourth Fifth DTaP/DTP/DT/Td (diphtheria, tetanus, and [acellular] pertussis) OR (tetanus and diphtheria only) MMR (measles, mumps, and rubella) HIB MENINGITIS (Haemophilus Influenzae B) (Required for child care/preschool only) HEPATITIS B VARICELLA (Chickenpox) OTHER OTHER PART III ADDITIONAL INFORMATION FROM HEALTH EXAMINER (optional) and RELEASE OF HEALTH INFORMATION BY PARENT OR GUARDIAN RESULTS AND RECOMMENDATIONS Fill out if patient or guardian has signed the release of health information.! Examination shows no condition of concern to school program activities. I give permission for the health examiner to share the additional information about the health check-up with the school as explained in Part III.! Please check this box if you do not want the health examiner to fill out Part III.! Conditions found in the examination or after further evaluation that are of importance to schooling or physical activity are: (please explain) Signature of parent or guardian Name, address, and telephone number of health examiner Date Signature of health examiner Date PM 171 A (1/01) (Bilingual) If your child is unable to get the school health check-up, call the Child Health and Disability Prevention (CHDP) Program in your local health department. If you do not want your child to have a health check-up, you may sign the waiver form (PM 171 B) found at your child s school.

13 Oral Health Assessment Form T07-003, English, Arial Font Page 1 of 1 Oral Health Assessment Form California law (Education Code Section ) states your child must have a dental check-up by May 31 of his/her first year in public school. A California licensed dental professional operating within his scope of practice must perform the check-up and fill out Section 2 of this form. If your child had a dental check-up in the 12 months before he/she started school, ask your dentist to fill out Section 2. If you are unable to get a dental check-up for your child, fill out Section 3. Section 1: Child s Information (Filled out by parent or guardian) Child s First Name: Last Name: Middle Initial: Child s birth date: Address: City: Apt.: ZIP code: School Name: Teacher: Grade: Child s Sex: Male Female Parent/Guardian Name: Child s race/ethnicity: White Black/African American Hispanic/Latino Asian Native American Multi-racial Other Native Hawaiian/Pacific Islander Unknown Section 2: Oral Health Data Collection (Filled out by a California licensed dental professional) IMPORTANT NOTE: Consider each box separately. Mark each box. Assessment Visible Decay Date: Present: Caries Experience (Visible decay and/or fillings present) Yes No Yes No Treatment Urgency: No obvious problem found Early dental care recommended (caries without pain or infection; or child would benefit from sealants or further evaluation) Urgent care needed (pain, infection, swelling or soft tissue lesions) Licensed Dental Professional Signature CA License Number Date Section 3: Waiver of Oral Health Assessment Requirement To be filled out by parent or guardian asking to be excused from this requirement Please excuse my child from the dental check-up because: (Check the box that best describes the reason) I am unable to find a dental office that will take my child s dental insurance plan. My child s dental insurance plan is: Medi-Cal/Denti-Cal Healthy Families Healthy Kids Other None I cannot afford a dental check-up for my child. I do not want my child to receive a dental check-up. Optional: other reasons my child could not get a dental check-up: If asking to be excused from this requirement: Signature of parent or guardian Date The law states schools must keep student health information private. Your child's name will not be part of any report as a result of this law. This information may only be used for purposes related to your child's health. If you have questions, please call your school. Return this form to the school no later than May 31 of your child s first school year. Original to be kept in child s school record.

14 Albert Einstein Academy Kindergarten Requirements Checklist Copy of a current immunization card. These vaccines are required for your child to attend public school: 5 doses DTaP (diphtheria tetanus pertussis) except that a total of 4 doses is acceptable if at least one dose was given on or after the 4th birthday 4 doses of Polio (IPV) except that a total of 3 doses is acceptable if at least one dose was given on or after the 4th birthday 3 doses Hepatitis B 2 doses MMR (measles mumps rubella) both given on or after the first birthday 1 dose of Varicella (chicken pox vaccine). Copy of your child s birth certificate Report of Health Examination for School Entry form completed by a licensed physician. Oral health assessment form completed by a licensed dentist. If you have any health related question please feel free to contact the school nurse at beverlyhills@ealas.org.

15 Odyssey Academy Beverly Hills Free and Reduced Lunch Information Dear Parent/Guardian: Children need healthy meals in order to learn effectively. The Albert Einstein Academy offers healthy meals every school day. Your children may qualify for free meals or for reduced price meals: If you now receive Food Stamps, California Work Opportunity and Responsibility to Kids (CalWORKs), Kinship Guardianship Assistance Payments (Kin-GAP), or Food Distribution Program on Indian Reservations (FDPIR) benefits, your child may receive free meals. If your total household income is the same or less than the amounts on the income scale found in the federal government reduced income eligibility guidelines ( your child may receive meals free or at a reduced price. Household means a group of related or nonrelated individuals who are living as one economic unit and sharing living expenses. Living expenses include rent, clothes, food, doctor bills, and utility bills. A foster care child who is the legal responsibility of the welfare agency or ward of the court may be eligible to receive meals free or at a reduced price regardless of your income. Foster children must have a separate application from other children in your household, and their eligibility is based on their Personal Use Income. HOW TO APPLY Contact the school for an Application for Free and Reduced-Price Meals or Free Milk, and return it to the school as soon as possible. The application cannot be approved and may be returned if it contains incomplete eligibility information. CONFIDENTIALITY Family size, household income, and Social Security number information will remain confidential and will not be shared for any purpose. Information you provide will determine your child/children s eligibility to receive free or reduced-price meals. You will be notified by the school when your application has been approved or denied for free or reduced-price meals.