Student Enrollment Policy Packet

Transcription

1 Student Enrollment Policy Packet Welcome to the next step for enrollment into Mountain View Virtual. Use this page as your cover sheet and checklist. Please follow directions closely; failure to provide the correct documents may lengthen the enrollment process. Student Legal Name Today s Date: First: Last: Middle: D.O.B. Parent/Guardian Name (if student is under 19) Parent/Guardian Name (if student is under 19) First: First: Last: Contact Info Home Phone: Referred by: Mobile Phone: Last: Please provide copies of the following documents Student s State Approved Birth Certificate (REQUIRED) Student s Immunization Record Student s Most Recent Report Card/Unofficial Transcript Proof of Residency (REQUIRED) Please complete, sign and return the following attached documents Student Enrollment Agreement, page 2 Student Service Intake Information, page 3 Home Language Survey, page 4 Request for Records, page 5 Family Education Rights & Privacy Act Acknowledgement (FERPA), page 6 Student Info & Photo Release, page 6 Affidavit of State of Colorado Residency, page 9 Parent/Student Handbook Acknowledgement, page Application for Free & Reduced Lunch, page 13 The following documents are REQUIRED if applicable to the enrolling student Copy of Individualized Education Program (IEP) Copy of 504 Copy of legal guardianship paperwork Letter to accompany proof of residency Three ways to return your completed forms and documents Mail: Scan and to: Docs@mountainviewvirtual.com Fax: Enrollment Contact Center MVV 900 South Gay Street Ste Knoxville, TN docs@mountainviewvirtual.com MVV Enrollment Contact Center Enrollment fax Mountain View Virtual All Rights Reserved Page 1 Rev 6/10/2015

2 Student Enrollment Policy Packet Student Enrollment Agreement I understand that I am enrolling (student name) in a school that operates in a virtual environment. Enrolling in this school means that your student will be attending a public school that has no physical classroom but still must meet all requirements for public schools in Colorado. These requirements include but are not limited to: meeting compulsory attendance requirements, participating in state standardized testing (PARCC, ACT, CMAS, WIDA ACCESS and Bench Mark Assessments) and communicating regularly and professionally with school staff. I understand that while there is more flexibility than in a traditional school, students are still expected to attend school five days a week for an average 5-7 hours per class per week. I understand that participation in state standardized tests may require travel. Additional expectations are posted in the Parent/Student Handbook. I understand that students are expected to attend all assigned synchronous classes and login daily to the Mountain View Virtual system. Students who accrue four (4) unexcused absences in a month or ten (10) during a school year are considered truant according to Colorado state statute. I understand that students and their parents or legal guardian(s) are subject to school- based truancy policy and practices. I also understand that students are also required to participate in all state and school standardized testing and to comply with the terms of the Parent/Student Handbook. State law provides that parents/legal guardians are responsible for ensuring that their student attends school. I understand that students must complete assigned lessons, submit specified assignments to their teachers online, and complete assessments. Students and/or their parents/legal guardians or designated representative are expected to participate in regular telephone, e- mail, web conferencing, or if required, in- person contact with an academic advisor. High School students are expected to perform their school work independently. While students may not need adult supervision during the school day, they must still be in a safe and secure environment. I understand that by enrolling in an online school, I will need to provide my child with a computer that meets the school s minimum technical requirements as well as reliable internet access. Student Printed Name (REQUIRED) Student Signature (REQUIRED) Adult Student/Parent/Legal Guardian Printed Name (REQUIRED IF STUDENT IS A MINOR) Adult Student/Parent/Legal Guardian Signature (REQUIRED IF STUDENT IS A MINOR) docs@mountainviewvirtual.com MVV Enrollment Contact Center Enrollment fax Mountain View Virtual All Rights Reserved Page 2 Rev 6/10/2015

3 Student Enrollment Policy Packet Student Service Intake Information Mountain View Virtual is fully committed to providing quality education to all of our students, including those with special needs. We need your help, so please complete this page with care. STUDENT NAME: DOB: Parent/Legal Guardian/Adult Student Signature (REQUIRED) SECTION 1 Check Yes or No as applicable Has your child ever been evaluated for special education? If yes, what was the evaluation date and what school/facility conducted testing: Does the student have a current IEP or 504 or does she/he currently qualify for one? If yes, please complete section 2 of this form. Does the student have an expired IEP or 504? If yes, please provide evaluation and expiration dates: Does your student take medication for any medical reason (ADHD, Diabetes, etc.)? If yes, what medication? Yes What is the date of the student s last hearing screening? Does the student wear glasses? What is the date of the student s last vision screening? Does the student use a hearing aid? No SECTION 2 FILL OUT ONLY IF YOUR CHILD HAS A CURRENT IEP OR 504 PLAN What type of plan does your Student have? IEP - Expiration Date: 504 Plan Expiration Date: If your student has either of these, Mountain View Virtual must receive a copy in order to process your enrollment Diagnosis (check all that apply): Learning Disability in Reading Math Written Expression Mental Retardation Traumatic Brain Injury Other Health Impairment Emotional Disturbance/Behavior Disorder Speech/Language Impairment Visual Impairment Hearing Impairment Orthopedic (Physical) Impairment Autism Other: Child with a Developmental Delay docs@mountainviewvirtual.com MVV Enrollment Contact Center Enrollment fax Mountain View Virtual All Rights Reserved Page 3 Rev 6/10/2015

4 Student Enrollment Policy Packet Home Language Survey The Office of Civil Rights (OCR) and the Department of Education require that school districts and charter schools identify English Language Learner (ELL) students in order to provide appropriate language instructional programs for them. Mountain View Virtual has selected the Home Language Survey as the method for determining if the student is a language- minority student. STUDENT NAME: DOB: What is the student s first language? Does the student speak a language fluently other than English? YES NO If yes, specify the language(s) What language(s) is/are spoken in your home? Has the student attended school in the United States in the past 3 years? YES NO If yes, complete the following Name of school State Dates Attended Name of school State Dates Attended Name of school State Dates Attended Parent/Legal,Guardian/Adult Student Signature (REQUIRED) Mountain View Virtual has the responsibility under the federal law to serve students who are limited English proficient and need English instructional services. Given this responsibility, Mountain View Virtual 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, Mountain View Virtual may conduct screenings or ask for related information about students who are already enrolled in the school as well as from students who enroll in the school in the future. Mountain View Virtual uses the WIDA ACCESS & WIDA APT as its English Language Assessments. The school must administer the WIDA ACCESS to a student during the enrollment process so that a student s enrollment status can be determined. docs@mountainviewvirtual.com MVV Enrollment Contact Center Enrollment fax Mountain View Virtual All Rights Reserved Page 4 Rev 6/10/2015

5 Student Enrollment Policy Packet Request For Records Parent/Legal Guardian/Adult Student Complete Top Portion Only Mountain View Virtual will use this form to request records from your student s most recent school(s) attended. Please return this form with your completed packet. You do not need to deliver this form to your student s current/former school. Student Name: DOB: Student s Former School: Dates attended: Grade: School Address: City: State: Zip: School Phone Number: School Fax Number: Student s Former School: Dates attended: Grade: School Address: City: State: Zip: School Phone Number: School Fax Number: Parent/Legal Guardian/Adult Student Signature (REQUIRED) Attn: School Records Clerk From: Mountain View Virtual The above named student has enrolled at Mountain View Virtual for the school year. Please provide the following records/documents: Withdrawal documentation Attendance Record Individualized Education Program (IEP) Official Transcript Behavior Records 504 documents Current progress report TCAP and ACT scores CELA Place/CELA Pro/W- APT/WIDA Access Birth certificate Health records ICAP Immunization Vision and Hearing Screening Advanced Learning Plan Please forward all Educational Records to: Data Owner Mountain View Virtual 7730 E. Belleview Ave, AG9 Greenwood Village, CO Fax: or Authorized Mountain View Virtual Signature Date docs@mountainviewvirtual.com MVV Enrollment Contact Center Enrollment fax Mountain View Virtual All Rights Reserved Page 5 Rev 6/10/2015

6 Student Enrollment Policy Packet FERPA Acknowledgement Form The Family Education Rights and Privacy Act (FERPA) affords parents and students certain rights and responsibilities regarding the student s education records. Mountain View Victual s FERPA policy can be found on the subsequent form and may be retained for your records. Mountain View Virtual and its designated curriculum provider, EdisonLearning, Inc., have found that to best serve the student s education needs, it is necessary to disclose a student s name and address to the classes of vendors identified in the subsequent policy document that provide important services related to your student s education. In all cases, these vendors will have agreed to ensure the confidentiality of the student s name and address and not to use the information for purposes other than that contracted for the student s educational needs. Please review the policy and sign the below acknowledgement. FERPA Acknowledgement (required for all students) To best serve the student, Mountain View Virtual requests the following 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 that Mountain View Virtual can best meet my student s education needs. STUDENT NAME: DOB: Parent/Legal Guardian/Adult Student Signature (REQUIRED) Student Information and Publicity Release Form Publicity Release Opt Out (optional, complete only if wishing to opt out) Mountain View Virtual likes to celebrate our students and their successes and achievements. From time to time our school staff and marketing departments may take photographs or videos at school activities and events and we ask for your permission to use any images of your student for commercial and non- commercial purposes including print, digital/electronic, via the Internet and otherwise. If the student s name is used, only the student s first name will be used, unless requested otherwise and explicitly. If this limited and defined use is acceptable, no other action is required. If it is not acceptable you have the right to deny such a request in the area below. Mountain View Virtual will also publish a school directory available only to Mountain View Virtual families. The information used in the directory will be limited to household address, phone number and addresses on file for the student and parents. If you wish for this information to not be released you may request that in the area below Check any boxes that apply and sign below: I DO NOT release limited use of my student s image and likeness for commercial and non- commercial use. I DO NOT release household information (name, address, phone numbers, and address) for a school directory Student s Name Parent/Legal Guardian/Adult Student Signature Date docs@mountainviewvirtual.com MVV Enrollment Contact Center Enrollment fax Mountain View Virtual All Rights Reserved Page 6 Rev 6/10/2015

7 Student Enrollment Policy Packet P Mountain View Virtual FERPA Policy For Your Records Annual Notice of Rights under the Family Educational Rights and Privacy Act (FERPA) Mountain View Virtual protects the confidentiality of personally identifiable information regarding its eligible, thought to be eligible, and protected handicapped students (if not protected by IDEA) in accordance with the Family Educational Rights and Privacy Act of 1974 (FERPA) and implementing regulations as well as IDEA and its implementing regulations. Education records are records that are directly related to the student, including computer media and videotape, which are maintained by an educational agency or by a party acting for the agency. Educational agency, for purposes of this notice, means Mountain View Virtual. For all students, the educational agency maintains education records which include but are not limited to: Personally identifiable information is confidential information that includes but is not limited to the students name, name of parents and other family members, the address of the student or student s family, and personal information or personal characteristics which would make the student s identity easily traceable. Directory information is information contained in an education record of a student which would not generally be considered harmful or an invasion of privacy if disclosed. It includes but is not limited to, the student s name, address, telephone number, electronic mail address, photograph, date and place of birth, major field of study, grade level, enrollment status (e.g., undergraduate or graduate, full- time or part- time), participation in officially recognized activities and sports, weight and height of members of athletic teams, dates of attendance, degrees, honors and awards received, and the most recent previous educational agency or institution attended. The Family Educational Rights and Privacy Act (FERPA) afford parents and students over 18 years of age ( eligible students ) certain rights with respect to the student s education records. They are: Parents have the right to inspect and review a child s education record. Mountain View Virtual will comply with a request to inspect and review education records without unnecessary delay and before any meeting regarding and IEP or any due process hearing, but in no case more than 45 days after the request has been made. Requests should be submitted in writing, indicating the records the parents wish to inspect, to the school principal or other designated school official. Parents have the right to a response from the school to reasonable requests for explanations and interpretations of the records. Parents have the right to request copies of the records. While Mountain View Virtual cannot charge a fee to search for or to retrieve information, it may charge a copying fee as long as it does not effectively prevent the parents from exercising their right to inspect and review the records. Parents have the right to appoint a representative to inspect and review their child s records. If any education record contains information on more than one child, parents have the right only to inspect and review the information relating to their child. If parents think information in an education record is inaccurate, misleading or violates the privacy or other rights of their child, they may request amendment of the record. Requests should be in writing and clearly identify the part of the record they want changed, and specify why it is inaccurate or misleading. Mountain View Virtual will decide whether to amend the record and will notify the parents in writing of its decision. If Mountain View Virtual refuses to amend a record, it will notify the parents of their right to a hearing to challenge the disputed information. Additional information regarding the hearing procedures will be provided to the parents or eligible student when notified of the right to a hearing. Mountain View Virtual will inform parents when personally identifiable information is no longer needed to provide educational services to a child. Such information must be destroyed at the request of the parents. Parents have a right to receive a copy of the material to be destroyed. However, a permanent record of a student s name, address, and telephone number, his or her grades, attendance record, classes attended, grade level completed, and year completed may be maintained without the limitation. Destruction of records means physical destruction or removal of personal identifiers from information so that the information is no longer personally identifiable. The school will provide, upon request, a listing of the types and locations of education records maintained, the school officials responsible for these records, and the personnel authorized to see personally identifiable information. Such personnel receive training and instruction regarding confidentiality. The school keeps a record of parties obtaining access to education records, including the name of the party, the date access was given, and the purpose for which the party is authorized to use the records. Parents have the right to consent or refuse to consent to disclosure of personally identifiable information contained in the student s education records, except to the extent that FERPA authorizes disclosure without consent. Consent means: the parent (s) have been fully informed regarding the activity requiring consent, in their native language or other mode of communication; they understand and agree in writing to the activity; and they understand that consent is voluntary and maybe revoked at any time, information may be disclosed without consent to school officials with legitimate educational interests. A school official is a person employed by the school, supervisor, instructor, or support staff member (including health or medical staff and law enforcement unit personnel); state agency representative, person or company with whom the school has contracted to perform a special task (such as an attorney, auditor, medical consultant, or therapist); or a parent or student serving on an official committee, such as a disciplinary or grievance committee, or assisting another school official in performing his or her tasks. A school official has a legitimate educational interest if the official needs to review an education record in order to fulfill his or her professional responsibility. Directory information may be released without parent consent. Parents have the right to refuse to let an agency designate any or all of the above information as directory information. Upon written request, Mountain View Virtual discloses education records without consent to officials of another school district in which a student seeks or intends to enroll. Parents have a right to file a complaint with the U.S. Department of Education concerning alleged failures by Mountain View Virtual to comply with the requirements of FERPA. Complaints may be filed with the Family Policy Compliance Office, U.S. Department of Education, 400 Maryland Avenue, S.W., Washington, D.C Mountain View Virtual and its designated curriculum provider, EdisonLearning, Inc., 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 confidentiality of the student s name and address and not to use the information for purposes other than that contracted for the student s educational needs. Suppliers of computers and educational materials for purposes of shipping to/from the student s home Customer care providers that handle overflow calls for Mountain View Virtual Internet service provider Companies that enter the student information into a computer database for use by school officials Other contractors and subcontractors that Mountain View Virtual or EdisonLearning, Inc. identifies as necessary to providing education service docs@mountainviewvirtual.com MVV Enrollment Contact Center Enrollment fax Mountain View Virtual All Rights Reserved Page 7 Rev 6/10/2015

8 Student Enrollment Policy Packet Proof of Residency AFFIDAVIT OF STATE OF COLORADO RESIDENCY Pursuant to 1CCR301-71, Rules for the Administration, Certification and Oversight of Colorado Online Programs, the Colorado State Board of Education must ensure that student residency is documented and verified, both upon initial enrollment and annually thereafter. Colorado residency is determined by the student and Parent or legal guardian currently residing within the State of Colorado boundaries, except for students of military families that maintain Colorado as their state of legal residence for tax and voter registration purposes. Reasonable evidence of residency within the State of Colorado boundaries can be established by a written statement of residency from the student s parent/guardian pursuant to Section : Instructions: The I swear statement on the next page, is an example of valid documentation for establishing proof of residency for an online student, per Rule 1CCR Section Rule 1CCR states that an Online Program must verify and document student residency in the State of Colorado upon enrollment and annually thereafter and retain a copy of the document or written statement offered as verification in the student s mandatory permanent record. The written statement of residency should follow Section (a) and (b) C.R.S. with regard to physical presence within the state and a purpose and intent to remain for an undetermined period. In addition for Colorado Online Programs, the student and Parent or legal guardian must be currently residing within the State of Colorado boundaries, except for students in military families pursuant to Section of the Rules. The I swear statement on the next page should be completed by the Parent or legal guardian of the student(s). All of the requested information must be completed and the statement signed and dated by the Parent or legal guardian. Note: Address cannot be post office box or general delivery at a post office. No vacant lot or business address shall be considered a residence. This document may be subject to additional audit review procedures to verify that the student and Parent or legal guardian are currently residents of the S tate of Colorado during the school year. A new form must be completed for each new school year and may be completed during the spring enrollment period. docs@mountainviewvirtual.com MVV Enrollment Contact Center Enrollment fax Mountain View Virtual All Rights Reserved Page 8 Rev 6/10/2015

9 Student Enrollment Policy Packet Student s name: Proof of Residency AFFIDAVIT OF STATE OF COLORADO RESIDENCY Pursuant to 1CCR301-71, Rules for the Administration, Certification and Oversight of Colorado Online Programs, the Colorado State Board of Education must ensure that student residency is documented and verified, both upon initial enrollment and annually thereafter. Colorado residency is determined by the student and Parent or legal guardian currently residing within the State of Colorado boundaries, except for students of military families that maintain Colorado as their state of legal residence for tax and voter registration purposes. Reasonable evidence of residency within the State of Colorado boundaries can be established by a written statement of residency from the student s parent/guardian pursuant to Section : Please complete the below affidavit as evidence of your residency status for the Colorado State Board of Education. Affidavit by Parent or Legal Guardian: I,, do hereby swear and affirm, under (Print Parent/Guardian Name) penalty of perjury, that my child(ren) and me are currently and will continue to be residents of the State of Colorado for the 2015/2016 school year. Parent/Guardian Signature: Date: Name: Address: City Apt. # Street County State Zip Note: Address cannot be post office box or general delivery at a post office. No vacant lot or business address shall be considered a residence. Children Enrolled at: Mountain View Virtual docs@mountainviewvirtual.com MVV Enrollment Contact Center Enrollment fax Mountain View Virtual All Rights Reserved Page 9 Rev 6/10/2015

10 Student Enrollment Policy Packet Parent/Student Handbook Acknowledgement The most recent MVV student/parent handbook is available at moutainviewvirtual.com and clicking on the Our Academics tab. The Parent/Student Handbook contains important information about Mountain View Virtual, and I understand that I should consult the Executive Director regarding any questions not answered in the handbook. The School is not responsible for omissions in the handbook. The Executive Director reserves the right to amend the contents and reissue this book at any time. Final authority on all matters rests with the school administration and school board when applicable. It is the responsibility of the student and parents/guardian to review this student handbook periodically. I acknowledge I have received the Mountain View Virtual link to access the Parent/Student Handbook and understand that the student and parent/guardian are expected to read the entire handbook. My signature constitutes my assurance that I/we have read the handbook in its entirety. Student Printed Name (REQUIRED) Student Signature (REQUIRED) Parent/Legal Guardian Printed Name (REQUIRED IF STUDENT IS A MINOR) Parent/Legal Guardian Signature (REQUIRED IF STUDENT IS A MINOR) docs@mountainviewvirtual.com MVV Enrollment Contact Center Enrollment fax Mountain View Virtual All Rights Reserved Page 10 Rev 6/10/2015

11 Student Enrollment Policy Packet Request a Copy of your Colorado Birth Certificate The state of Colorado makes it simple for you to receive a certified copy of your Colorado Birth Certificate, regardless of what county you live in. To find out more information and/or to request a certified copy of your Colorado Birth Certificate, please contact the Department of Public Health and Environment. Contact information is as follows: Phone: Website: Mail: or vital.records@state.co.us CHEIS/CBON/ Colorado Department of Public Health and Environment Vital Records Section 4300 Cherry Creek Drive South HSVRD- VR- A1 Denver, CO Request a Copy of your Immunization Records The state of Colorado makes it simple for you to receive a certified copy of your Immunization Records, regardless of what county you live in. You may request copies of your/your child s immunization record by completing the Request to Release Immunization Record Form accessed through the Individuals>Request a Shot Record tab on our website: or call 1 (888) docs@mountainviewvirtual.com MVV Enrollment Contact Center Enrollment fax Mountain View Virtual All Rights Reserved Page 11 Rev 6/10/2015

12 Student Enrollment Policy Packet APPLICATION INSTRUCTIONS IF YOUR HOUSEHOLD RECEIVES BENEFITS FROM SNAP (SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM) OR FDPIR (FOOD DISTRIBUTION PROGRAM ON INDIAN RESERVATIONS), FOLLOW THESE INSTRUCTIONS: Part 1: List all students; indicate school and grade for each student. 2: List the name of the household member receiving the benefit, and list the case number. Part Part 3: Skip this part. Part 4: Skip this part. Part 5: If you do not want your information shared with Medicaid or SCHIP, check this box. 6: Sign the form. The last four digits of the social security number are NOT required. Part IF YOU ARE APPLYING FOR A HEAD START, MIGRANT, HOMELESS, OR RUNAWAY CHILD, FOLLOW THESE INSTRUCTIONS: Part 1: List all students; indicate school and grade for each student. Indicate if the student is Head Start, Homeless, Migrant or Runaway. Part 2: Skip this part. 3: Call [school, homeless liaison or migrant/head Start coordinator] Part Part 4: Skip this part. Part 5: If you do not want your information shared with Medicaid or SCHIP, check this box. Part 6: Sign the form. The last four digits of the social security number are NOT required. YOU ARE APPLYING FOR A FOSTER CHILD OR MULTIPLE FOSTER CHILDREN ONLY FOLLOW THESE INSTRUCTIONS: IF 1: List all students; indicate school and grade for each student. Check the foster check box for each foster child. Part Part 2: Skip this part. Part 3: Skip this part. 4: Skip this part. Part 5: If you do not want your information shared with Medicaid or SCHIP, check this box. Part Part 6: Sign the form. The last four digits of the social security number are NOT required. FOR ALL OTHER HOUSEHOLDS, INCLUDING WIC AND HOUSEHOLDS THAT HAVE FOSTER CHILD(REN) LIVING WITH THEM ALONG WITH NON- FOSTER CHILD(REN), FOLLOW THESE INSTRUCTIONS: Part 1: List each child s name, school, and grade. If the child is a foster child, check the foster box. For all students listed, if NO INCOME, you must check the no income box. Part 2: Skip this part. Part 3: Skip this part. Part 4: Follow these instructions to report all household income. Income can be from the previous month, this month, or your projected income for month. next Column 1 Name: List the first and last name of each person living in your household, related or not (such as grandparents, other relatives, or friends). You must include yourself and all children living with you not listed in Part 1 and students that have income. Attach another sheet of paper if you need to. Column 2 Check if no income: If the person does not have any income, check the box. Column 3 6 Gross income and how often it was received: Next to each person s name, list each type of income received and how often it was received. Earnings from work: example: If you are paid $ bi- weekly, please record $ in the income blank and mark the bi- weekly check box. Gross income is the amount earned before taxes and other deductions. Additional Income Sources: List the total amount each person received from all other sources. For example: If you receive $ monthly for child support, please record $ in the income blank and mark the monthly check box. Other Income: Report net income for self- owned business, farm, or rental income. Next to the amount, check how often the person receives it. If you are in the Military Housing Privatization Initiative, do not include this housing allowance. Part 5: If you do not want your information shared with Medicaid or SCHIP, check this box. Part 6: An adult household member must sign the form and provide the last four digits of his or her Social Security Number or mark the box if he or she does not have one. INCOME TO REPORT: Earnings from Work Wages/salaries/tips Strike benefits Unemployment Compensation Worker s Compensation Net income from self- owned business or farm Welfare/Child Support/Alimony Public assistance payments Welfare payments Alimony Child support payments Pensions/Retirement/ Social Security/SSI/VA Benefits Pensions Supplemental Security Income Retirement income Veteran s benefits Social Security Other Income Disability benefits Cash withdrawn from s avings Interest/Dividends Income from Estates/Trusts/ Investments Regular contributions from people not living in the household Net royalties/annuities/ rental income Any other income docs@mountainviewvirtual.com MVV Enrollment Contact Center Enrollment fax Mountain View Virtual All Rights Reserved Page 12 Rev 6/10/2015

13 Application for Free and Reduced Price School Meals (This form may be used only if participating in the federal Child Nutrition programs) Last Name(s) of Family Mailing Address, City, Zip Code Telephone Number INSTRUCTIONS: Using the instruction sheet provided, complete the application, sign your name, and return application to school. Part 1. Student Information. List all students attending school in the district; provide school and grade information. Check the foster child check box for all students that are the legal responsibility of a welfare agency or court. If the student has NO INCOME, you MUST check the No Income box. If the student has income please add the student to the household section below and provide income information. Foster Child No Income HDS: Head Start; H: Homeless; M: Migrant; R: Runaway Student Name: Last, First School Grade HDS H M R Part 2. Supplemental Nutrition Assistance Program (SNAP) /Food Distribution Program on Indian Reservations (FDPIR): Provide the name and case number for the person who receives benefits. (Enter information and skip to part 5) Name: Case Number: Part 4. List all household members not listed above AND students with income. Earnings from work before No Name: Last, First deductions, or Income unemployment List all current gross income, and check how often it was received. Welfare, child support, alimony Pensions, retirement, Social Security, SSI, VA benefits Other Part 3. Other Source Eligibility: If any child you are applying for is HEAD START, HOMELESS, MIGRANT, OR RUNAWAY, check the appropriate box to the left and call [your school, homeless liaison, migrant coordinator at phone #] Part 5. MEDICAID AND/OR STATE CHILDREN S HEALTH INSURANCE PROGRAM (SCHIP) The information provided in the application may be shared with Medicaid or SCHIP offices to seek enrollment of children into the above programs. You are not required to consent to the disclosure of this information; this will not affect your student(s) eligibility for school meals. Your information WILL be shared unless you check the box below. Please do NOT share my information with the Medicaid or SCHIP offices. Part 6: Signature and Last Four Digits of Social Security Number: An adult household member must sign the application. If Part 4 is completed, the adult signing the form must also list the last four digits of his or her Social Security Number or mark the I do not have a Social Security Number box. Social Security Number (Last 4 digits only): XXX - XX - I do not have a Social Security Number I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get federal funds based on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted. I understand my child s eligibility status may be shared as allowed by law. Sign here: X Date: ***************DO NOT WRITE BELOW THIS LINE. DISTRICT USE ONLY*************** Annual Income Conversion: Weekly x 52; Bi-Weekly 1 x 26; 2 Times per Month x 24; Monthly x 12 Total Income: Per Week, Bi-Weekly, 2x/Month, Month, Year Household size: Eligibility: Free Reduced: Denied: Income Categorically Eligible App Num.: Determining Official s Signature: Date: Withdrawn Date: