REQUEST FOR STUDENT RECORDS
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1 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 you 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.
2 c/o Merit School of Music 38 South Peoria Street Chicago, Illinois Phone Fax Student Transportation Form To ensure the safety of your child, CVCS requires that you confirm how your 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 your compliancy documents. Thank you in advance for your 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 your 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)
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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: Type of Health Insurance: HMO Medicare No Health Insurance Other If the student is covered by Medicare, provide the Medicare number: Read and Check: I understand that for those school health and health-related services that the Medicare-eligible student may 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 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 your authorization to release your child from school. Please note that they will be the only ones who can release your child. A valid ID must be presented at all times to the office clerk, and they must be 18 years or over.
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