San Jose Unified School District Liberty on-line Program

Transcription

1 San Jose Unified School District Liberty on-line Program Instructions: Enrollment Checklist 1. Call Liberty Virtual to determine appropriate placement. Fill out the online application. 2. Complete all of the items in the checklist below for each student applying to the program. If you have any questions or need assistance, please call Liberty Virtual Program Coordinator Arooj Syed (408) Note: Students are not officially enrolled until all completed forms have submitted; all additional required documentation for the student has been reviewed by the school Guidance, and it has been determined that the student meets the criteria for acceptance. Checklist: Student online application completed and signed. Additional Student Information form completed (page 2) Enrollment Acceptance form completed and signed (page 3) Agreement for Use of Instructional Property form completed and signed (page 4 and 5) Family Educational Rights and Privacy Act (FERPA) Consent Form Signed (page 5 and 6) San Jose Unified School District Enrollment forms ( 3 pages ) Parent/Student Confirmation completed and signed (page 9) Student Records Release form completed and signed (page 10) California Report of Health Examination for School Entry form completed and signed (print and completed) California Report of Health Examination for School Entry - PDF. Proof of age (official copy of the applicant s birth certificate) Verification of residence in the State of California is required to enroll Kaplan Academy of California. Verification of residence in one of the following counties is required to enroll in Kaplan Academy of California. San Francisco Bay: San Mateo, Alameda, San Francisco, Santa Clara, or Santa Cruz. Acceptable verification must be in the parent/legal guardian s name. Valid and current driver License or state-issued ID required. PLUS one of the following current unpaid utility bill, valid home owner s or property deed, residential lease, welfare documents from the California Department of Social Services, Social Security documents, or notarized rent verification statement. Student Immunization records. Transcript (s) for all high school credit earned to date (must include all transcript for each grade completed) Discipline Behavior Report from last school attended. If applicable, diagnostic exam results and a copy of IEP or 504/508 Plan. 3. Go to district of residence and obtain an approved inter-district transfer to SJUSD and request for Liberty on-line program. 4. Bring or have your school district of residence send an approved inter-district transfer to SJUSD. 5. If the inter-district transfer is approved, you will be instructed on what to bring to SJUSD s enrollment Center to complete the process.

2 Additional Student Information Student Information Student Name: Date of Birth: Current Grade: Parent s Name: Has the student taken the CAHSEE exam? Yes No Did the student pass CAHSEE Math? Yes No CAHSEE English/Language Arts? Yes No P

3 New Student Enrollment Form - LIBERTY VIRTUAL SCHOOL - San Jose Unified School District Student LEGAL Name: (from birth certificate) Last Name First Name: Middle Name: Grade: Male Female Birth Date: City of Birth: Birth Country: Previous School: City: State/ Country: Date left: Student(s) resides with (Circle): Parents Birth mother Birth father Legal guardian Other: Primary Parent/Guardian: Last: First: Relationship: FYI: Home address is the location where the students sleep each night. PO boxes will not be accepted as mailing address. Home Address: Apt: City: Zip: Home Phone: Cell: Bus. Phone: Secondary Parent/Guardian: Last: First: Relationship: Home Address: Apt: City: Zip: Home Phone: Cell: Bus. Phone: l: What special services has your child received at the previous school? (Please check all boxes that apply) Special Education: Resource (RSP) Speech/Language 504/508 Accommodation Plan Did you provide an Individualized Education Plan (IEP)? Yes No Has this student attended a Continuation/Alternative School? Yes No Is the student listed above expelled, being considered for expulsion or has been given a suspended expulsion from another school District? Yes No If Yes: Name of school: City HOME LANGUAGE SURVEY : 1. Which language did THE STUDENT learn when he/she first began to talk? 2. What language does THE STUDENT use most frequently at home? 3. What language does Parents/Guardians use most frequently to speak to the student? 4. Name the language in the order most often spoken by the Parents/Guardians at home Do you feel that THE STUDENT can communicate in English? Understand Yes No Reads Yes No Speaks Yes No Writes Yes No If a language other than English is indicated on any line above, can THE STUDENT communicate in that language? Language: Language: Understand Yes No Reads Yes No Speaks Yes No Writes Yes No In what language do you wish to receive school information: English Spanish Vietnamese When did this student first attend school in the United States? Date: Month Year I/We have reviewed this document and to the best of my/our knowledge, the information contained herein is true and complete: Parent/Guardian signature: Date: Office Use Only: District of Residence: Grade RSP/SI/504/508 Staff Enrolled: Input Approved by Liberty Virtual: Date by School Assigned: Liberty on-line: (438/538) Student ID Address provided Staff Verified:

4 San Jose Unified School District Liberty Virtual Student Health Information Dear Parent, Your answers to the following questions will provide valuable information that will assist SJUSD nurses and staff to plan your child s school program and identify Health Services needs. If your child does not have health insurance, free/low cost insurance is available through Medi- Cal, Healthy Families, Healthy Kids and Kaiser s Child Health Plan. Call for assistance. Student s Name Grade DOB: Student # Assigned School: 438/538 LIBERTY VIRTUAL Parent s Language: Mother/Guardian Daytime Phone Father/Guardian Daytime Phone PLEASE CHECK ALL THAT APPLIES TO YOUR CHILD: ADD/ADHD Freq. Ear Infections Frequent Headaches Frequent Nosebleeds Asthma Eczema Heart Problems Seizures Chicken Pox Fainting Spells Joint Pains Tires Easily Diabetes Type I Type II Frequent Colds Weight problems LIST ALL MEDICATION, WITH DOSE, TAKEN BY YOUR CHILD Seasonal Allergy Severe Allergy Epi-Pen AT HOME AT SCHOOL Does student wear glasses or contact lenses YES NO Does student wear hearing aids or have a history of hearing problems? YES NO DOES YOUR CHILD HAVE HEALTH INSURANCE? YES NO If yes, please check type: Medi-Cal Healthy Families Healthy Kids Kaiser Child Program Private insurance Does your child have a health care provider they visit regularly? Yes No Primary Physician or Health Clinic: Date of Last Physical Exam Dentist: Date of Last Dental Exam When your child is sick, where do you take him/her? Doctor s Office Emergency Room Healer Keep child home Other, please explain During the past year, has your child ever experienced any asthma symptoms such as coughing, wheezing, shortness of breath, chest tightness or phlegm? Not at all Less than every month Every month Every week Every day Not sure HAS YOUR CHILD HAD ANY SERIOUS ILLNESS, OPERATIONS OR ACCIDENTS? If yes, when did this occur? Was she/he admitted to the hospital? Yes No WAS YOUR CHILD SEEN AT A HOSPITAL EMERGENCY ROOM DURING THE LAST YEAR? Yes No If yes was it for: Injury Asthma Diabetes Other How many times? Has your child attended school in Santa Clara County within the last 12 month? Yes No Parent Signature Date: Status Requirement: All requirements are met: Record Verified: Date: Staff Initial: Currently, up-to-date, but more doses are due late: TB test needed MV: 30 day letter: Exemption granted for (circle): Personal belief Medical Permanent Temporary: VAR MMR DTP Polio PPD

5 New student Enrollment form, continued - Liberty Virtual School Student Last Name: First Name: Student ID # Studentʼs Ethnicity/Race: The Federal Government requires an ethnic designation for each student. Directions: Check the one category... which best describes your student - OPTIONAL ETHNICITY: Mark the ethnicity with which the student most closely identifies: Please check one: (1) Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race) (2) Not Hispanic or Latino American Indian/Alaska Native Asian Filipino Black White/Not Hispanic Hispanic Pacific Islander Other WHAT IS YOUR CHILD S RACE (Please check up to five racial categories) The above part of the question is about ethnicity, not race. No matter what you selected above, please continue to answer the following by marking one or more boxes to indicate what you consider your race to be. American Indian or Alaskan Native (100) Chinese (201) Hawaiian (301) (Person having origins in any of the Japanese (202) Guamarian (302) original people of North and South Korean (203) Samoan (303) America (including Central America) Vietnamese (204) Tahitian (304) Asian Indian (205) Other Pacific Islander (399) African American/Black (600) Laotian (206) Filipino (400) Cambodian (207) White (700) Hmong (208) (Persons having origins in any Other Asian (299) of the original peoples of Europe, PARENT EDUCATION LEVEL: Check the response that describes the highest education level of parent/guardian(s): Not a high school graduate (A) High school graduate (B) Some College (C) College graduate (D) Graduate school/post graduate training (E) When did your student start 9 th grade: Month: Year: (Tag SG9)

6 Parent/Student Confirmation Parent Name: Student Name: Please initial each statement confirming that you understand and agree to the requirements and affirmations below. Student Student Both the parent and student are comfortable using a computer. The student is able to adhere to a schedule. The student can meet daily academic activity requirements and track progress. The student can make all scheduled appointments with teachers and/or advisors. There will be an appropriate place and space for the student to study at home or designated work area. If the student is under 18 years of age that the parent will give the student the necessary support to complete the program. The student is enrolling voluntarily. If age 18 or older, that the student has continuously been enrolled in high school since he or she was 18 years of age. The student has or is one or more of the following (circle all that apply): Deficit Credits, Special Needs, Travel Needs, Gifted or Talented, Previous Dropout, More Parent Involvement, or Other Reason. I have attended an Adult School. I have not attended an Adult School. Parent Signature Student Signature Date P

7 Academic Placement Attestatio Complete the information below as accurately as possible. This form must be completed and signed by both the student and the parent/guardian (if the student is under the age of 18). (Name of Current or Previous School) (City and State) (Grade) (Last Date of Attendance) Please fill in the courses taken by grade for all previous grades completed. Grade: 9 Grade: 10 Requirement Course Final Grade English Math Science Social Science Physical Education Foreign Language Fine Arts Credits Earned Currently Enrolled Yes /No Elective 1 Elective 1 Elective 2 Elective 2 Grade: 11 Grade: 12 Requirement Course Final Grade Credits Earned Currently Enrolled Yes /No English English Math Math Science Science Social Science Social Science Physical Education Physical Education Foreign Language Foreign Language Fine Arts Fine Arts Elective 1 Elective 1 Elective 2 Elective 2 Requirement Course Final Grade English Math Science Social Science Physical Education Foreign Language Fine Arts Requirement Course Final Grade Credits Earned Credits Earned Currently Enrolled Yes /No Currently Enrolled Yes /No Please read and sign below. I understand that student is being academically placed in courses for the first semester based on the information provided within this attestation. I understand that an official Records Release will be sent to student s previous school/district. Upon review of the official records, I understand that student may be placed in courses that meet his/her academic requirements. I also understand that student will be required to complete any delinquent courses and/or alter his/her course path based on previous learning history and/or educational learning requirements, which may include IEP or 504 Plan requirements. Student Name Student Signature Date Parent/Guardian Name (If student is under 18) Parent /Guardian Signature Date

8 Enrollment Acceptance Statement of Education Equality San Jose Unified School District does not discriminate on the basis of race, color, national origin, sex, sexual orientation, age, or disability in admission or access to, or treatment or employment in, its programs and activities. Acknowledgement of Expectations Please initial each of the following statements. I understand that I am enrolling my child in a public school with attendance requirements that he/she is expected to meet. I understand that public school enrollment includes participation in the required state testing program. I expect my child to have the guidance and support of a professional instructor in implementing the Liberty Virtual School program. I understand that student progress is an expected part of the Liberty Virtual School program in addition to the attendance hours logged. Instructors will review progress and consider other factors, including parental input, when making student advancement or disciplinary decisions. I understand that I am required to participate in regular conferences with my child s instructor(s). I understand that if my child enrolls both my child and I will be bound by the SJUSD Student Handbook. I understand that if my child enrolls both my child and I will be bound by the Master Agreement. I verify that all of the information contained in the application, including, without limitation, the Student Application, is complete and factually correct. If my child is attending Liberty Virtual as an Inter-district Transfer student, he/she will be unenrolled from SJUSD if he/she is dropped from Liberty Virtual School. Please accept this signed and completed document to enroll in the Liberty Virtual School of SJUSD. Student Name: Parent/Guardian Signature: Date: Date:

9 Technology Acknowledgement Form This form must be completed and signed by the student and parent/guardian (if the student is under the age of 18). The Liberty Virtual School requires that the student have access to a Windows, Linux or Mac OS computer with browser capability and dedicated internet access. Although broadband access is not required, it is preferable for downloading various multimedia required as part of course content. Please Check Yes or No Yes No Please read and sign below. By signing below I am confirming that the information stated above is true and accurate. Student Name Student Signature Date Parent/Guardian Name (If student is under 18) Parent/Guardian Signature Date Page 9 of 9