ENROLLMENT APPLICATION

Rev- 2.23.2015 2014-2015 ENROLLMENT APPLICATION RETURN THIS COMPLETED APPLICATION AND COPIES OF THE REQUIRED DOCUMENTS TO: ECOT 3700 SOUTH HIGH STREET SUITE 95 COLUMBUS, OHIO 43207 OR FAX BOTH SIDES OF THIS APPLICATION TO: FAX: 614-643-7777 WALK-IN OFFICE HOURS: MONDAY-FRIDAY 8:30 AM TO 5:00 PM *ALL PAGES OF THE APPLICATION ARE REQUIRED TO BE RETURNED FOR ADMISSION TO ECOT WWW.ECOTOHIO.ORG ECOT Application 2.23.2015.indd 1 2/23/2015 10:43:43 AM

CHECKLIST OF REQUIRED DOCUMENTS PLEASE KEEP YOUR CHILD ENROLLED IN HIS OR HER CURRENT SCHOOL WHILE APPLYING TO ECOT. IN ORDER TO COMPLETE THE ADMISSIONS PROCESS, YOUR APPLICATION MUST INCLUDE THE FOLLOWING REQUIRED DOCUMENTS. IF YOU HAVE QUESTIONS PLEASE CALL US: Signed and completed Enrollment Application Please read the Admissions Guide enclosed in this packet of information. The Admissions Guide will help guide you through the process and answer many questions you may have about ECOT. To enroll in ECOT, students must be between a minimum age of 5 by September 30th and no older than 21. Legal guardian must be an Ohio resident and same guardian must sign all signature lines in the application. We accept faxed or copied applications. Please send the application in the provided UPS envelope or mail to ECOT 3700 S High St Suite 95, Columbus, OH 43207 or fax both sides of the application to 614-643-7777. Students must be at least 18 years old to enroll as their own legal guardian. Please make sure to call the hotline at 1-888-684-4214, as there are additional documents required for admission. Copy of Birth Certificate or Hospital Birth Record with official seal Copy of Custody Order or Divorce Decree (required only if applicable, see pg. 3 of the application) Under Ohio law, proof of custody must be provided to ECOT for any student for which custody has been determined by a court. Please provide entire document with court stamp and judge s signature, including any separation agreements or shared parenting plans. Copy of Proof of Residency Please send one of the following items, which MUST include a full address (street, city, state, zip), a full date (day/month/year), and MUST be in the legal guardian s name*. No disconnect or shut off notices will be accepted. Must contain physical address, not just a P.O. Box. Please send a copy of ONE of the following: Gas, electric, water, sewage or waste removal bill or receipt of installation(dated within past 60 days) *Phone bills and cable bills are NOT acceptable. Current lease agreement (including the signature of the landlord and tenant and dated within the past year), most current mortgage statement, home owner s or renter s insurance declaration page or real property tax bill (dated within the past year). Pay statement or pay stub containing the address of the legal guardian (dated within past 60 days) Most recent bank statement (dated within past 60 days including parent/legal guardian address) Official document issued by a federal, state or county agency which administers benefits (dated within the past 60 days) (examples: notice of determination for food stamps or benefits issued by the county Dept. of Job and Family Services) *If none of the proof of residency items above are in the legal guardian s name, you must send a copy of one of the above items AND complete the enclosed residency affidavit, which must be signed by the legal guardian, the person with whom the legal guardian resides and be notarized. Please call us with questions. ITEMS ENCOURAGED TO BE SENT IN TO ASSIST IN SCHEDULING YOUR CHILD S CLASSES: State test scores (copies only) Student unofficial transcript or most recent grade card (copies only) All MFE/ETRs or IEPs (Multi-Factored Evaluation/ Evaluation Team Report or Individualized Education Plan) if your child has been identified as special needs. (copies only) 1 ECOT Application 2.23.2015.indd 2 2/23/2015 10:43:43 AM

GENERAL INFORMATION I WISH FOR THE STUDENT TO BE ACCEPTED (SELECT ALL THAT APPLY): 2014 2015 School Year I wish to be enrolled starting: / / I am re-enrolling in ECOT Guardian Change STUDENT INFORMATION Last Name: First Name: Middle Name: Suffix: Date of Birth: Age: Student Cell Phone: ( ) Provider: Has the student attended or previously applied at ECOT? City and State of Birth: County of Birth: Gender: Male Female Mother s Maiden Name: Student Home Language: Student Native Language: English Last School Attended: School District Parent/Legal Guardian lives in (required): Social Security (optional): Last Grade Student Grade Student will be attending County Parent/ Completed: at ECOT: Legal Guardian Lives In: Is this student currently on an individualized education plan (IEP) Yes No has not been identified? Yes No PARENT/GUARDIAN INFORMATION (OR STUDENT IF OWN LEGAL GUARDIAN) Do you suspect that your student may have a disability that If either of these answers are yes, please see page 4 to give further explanation. Name: Relationship: Home Phone: ( ) *Street Address: Apt/Lot/Unit: Cell Phone: ( ) Work Phone: ( ) City: State: Zip Code: May we contact the cell numbers listed via text message? Yes No E-Mail Address: Which number would you like Home Ph. Cell Ph. listed as your primary number? ALTERNATE GUARDIAN (must be living with and married to the above parent/legal guardian) Name: Relationship: Cell Phone: ( ) Address: Work Phone: ( ) Other Phone: ( ) OTHER BIOLOGICAL PARENT Name: Relationship: Home Phone: ( ) Address: Cell Phone: ( ) Work Phone: ( ) City: State: Zip Code: E-Mail: EMERGENCY CONTACTS (We will attempt to contact the following if unable to contact Parent/Legal Custodian) Name: Relationship: Home Phone: ( ) Other Phone: ( ) Name: Relationship: Home Phone: ( ) Other Phone: ( ) * Please include the full address with the apartment, unit or lot number. BAR CODE 2 ECOT Application 2.23.2015.indd 3 2/23/2015 10:43:43 AM

PRESENTLY, WHERE IS THE STUDENT LIVING? In a house or apartment In a shelter In a motel, hotel, car, campsite or trailer park due to lack of alternative housing With friends or family members (other than parent/guardian) due to loss of housing, economic hardship or similar reason Other, please explain: CUSTODY INFORMATION Were biological parents ever married? Yes No If yes, are they still married? Yes No Deceased PRESENTLY, WITH WHOM IS THE STUDENT LIVING? Biological mother and biological father Biological mother only (if divorced from biological father, please send custody documentation) Biological father only (please send custody documentation) Grandparent(s) (please send a power of attorney stamped as filed with the courts or custody documentation) Legal guardian other than above (please send custody documentation with a judge's signature) Custody of the state (please send custody documentation with a judge s signature and stamped by the clerk of courts) Student is own legal guardian (please call us for eligibility requirements) Other, please explain: Was student ever in the legal custody of another person? Yes No If yes, please provide the name and address below of the person at the time when custody was lost Name Address: Dates the student was in the legal custody of this person (month and year): PLEASE CHOOSE ONLY ONE OF THE FOLLOWING STATEMENTS BEFORE SIGNING THE AUTHORIZATION FOR ENROLLMENT: By signing the Authorization For Enrollment Form (page 10), I certify that I am/we are the legal guardian(s) of the child. It has never been necessary to establish custody through Juvenile Court or a Divorce/Dissolution proceeding. OR By signing the Authorization For Enrollment Form (page 10), I certify that I am/we are the legal guardian(s) of the child. Custody was established through the courts and the custody order that I have provided with this application is accurate and is the most current documentation of legal custody. 3 ECOT Application 2.23.2015.indd 4 2/23/2015 10:43:43 AM

DISABILITIES/SPECIAL EDUCATION (SEE SECTION 3 ADMISSIONS GUIDE) If your child has ever been tested for a disability, we need copies of the most recent Individualized Education Program (IEP) and Evaluation Team Report (ETR) or Multi-Factored Evaluation (MFE). It is important for the school to receive the IEP and MFE/ETR in order to appropriately serve your child. IF YOUR CHILD HAS NEVER BEEN EVALUATED FOR AN EDUCATIONAL DISABILITY, BUT YOU SUSPECT YOUR CHILD MAY HAVE A DISABILITY, YOU HAVE THE RIGHT TO REQUEST ASSISTANCE. PLEASE REFER TO THE ADMISSIONS GUIDE TO LEARN MORE ABOUT HOW TO REQUEST THIS ASSISTANCE. 1) Does the student have one of the following Special Needs documents that identifies the student as having a disability? Please check one or more that apply: Yes - IEP (Individualized Education Plan/Service Plan) Yes - ETR (Evaluation Team Report) No - The student has not been identified with a disability If you answered Yes to question 1, please complete all remaining questions, including questions 2, 3 and 4. If you answered No to question 1, skip to questions 5 and 6. 2) Please provide the IEP or ETR effective date: Month /Date /Year 3) What is the student s disability? 4) Please provide the name of the school district that identified the student as having a disability: 5) Do you suspect that your child may have a disability that has not been identified or addressed by a previous school? No Yes 6) Does the student require visual adaptive equipment to use a computer? No Yes If yes, please check all that apply below: Braille Braille Note Braille Output CCTV Daisy Reader Dragon Dictate JAWS Magnification Devices Morse Code Victor Reader Window Eyes ZoomText Other 4 ECOT Application 2.23.2015.indd 5 2/23/2015 10:43:43 AM

COMPUTER OPTIONS (SEE SECTION 5 IN THE ADMISSIONS GUIDE) PLEASE READ SECTIONS 3, 4, & 5 IN THE AD- MISSIONS GUIDE BEFORE FILLING OUT THIS FORM ECOT is an online school, students are required to use a computer for their schoolwork. You have four options to choose which computer will be used Please select an option below. CHOOSE ONE OPTION FROM OPTIONS 1-4: 1 ECOT Computer (Please send an ECOT computer to our home. It will have the hardware and software (including printer) needed to access ECOT curricula and only approved educational web sites.) 2 Shared ECOT Computer (We already have an ECOT computer that this student will share.) 3 My Own Personal Computer (PC) (Temporary) (We will use our own PC on a temporary basis until an ECOT computer is shipped to us.) INSTALLATION FORM FOR HIGH SPEED INTERNET (SEE SECTION 6, 7 OF THE ADMISSIONS GUIDE) PLEASE READ THE FOLLOWING AND SELECT ONE OF THE OPTIONS. THIS FORM ALLOWS ECOT TO INSTALL INTERNET ACCESS IN YOUR HOME IF IT IS DETERMINED THAT YOUR CABLE COMPANY PARTICIPATES IN THE ECOT PAID INTERNET PROGRAM. AFTER READING THE ADMISSIONS GUIDE, PLEASE SELECT ONE OF THE FOLLOWING: YES, Please check for serviceability from one of the broadband providers paid by ECOT. If service is not available, automatic enrollment into the Office Depot program will commence within 30 business days. NO, I will provide my own internet service at this time. If service is needed later, I will contact **If no selection is made above, ECOT will automatically check for serviceability. 4 My Own PC* (Permanent) (We will use our own PC instead of an ECOT computer.) *If at any time you decide you want to use an ECOT computer, please notify ECOT, and we will ship one within 30 days (with up-to-date Proof of Residency). * OPTION 4 IS DISCOURAGED. ECOT HELPDESK CAN ONLY OFFER LIMITED SUPPORT WHEN USING A HOME PC. By signing the Authorization For Enrollment Form (page 10), I acknowledge that I understand my choices and have selected one of the above computer options. I understand that I am responsible for the ECOT computer, if selected. ECOT s computer equipment is the property of the state and must be returned within 10 days of withdrawing from ECOT. If I choose to use my computer, now or in the future, ECOT is NOT responsible for monitoring my child s activity on the Internet and my child will potentially have access to offensive sites outside ECOT s secure system. I agree to cooperate in providing residential access for installation, when I select the option of ECOT provided broadband connection. ECOT contracts with vendors and cannot control the speed of installation, quality of service or interruption. 5 ECOT Application 2.23.2015.indd 6 2/23/2015 10:43:43 AM

ECONOMIC SURVEY 2014 2015 The information provided by this survey may be used to help ECOT qualify for reduced-cost services or federal grants that provide additional services for students. This information will remain confidential and be used for statistical purposes only. IMPORTANT: Even if your income does not meet these Income Eligibility Guidelines, you must return this completed survey. Student Full Name: Date of Birth: / / Grade: 1. How many people live in your home? (including children) 1 2 3 4 5 6 7 8 9 or more 2. What is your total MONTHLY family income (before taxes)? No income $972 or less $973-$1800 $1801-$2426 $2427-$3051 $3052-$3677 $3678-$4303 $4304-$4929 $4930-$5555 $5556-$6181 $6182-$6807 $6808 or more 3. 4. 5. 6. Is your family receiving Food Stamps? No Yes (case number ) Is your family receiving Ohio Works First (OWF)? No Yes (case number ) Is the student eligible to receive medical assistance under Medicaid? No Yes (case number ) Foster care: If this application is for a child who is a ward of the state (Institutionalized, Foster Care or Temporary Custody, check here and check his or her personal use monthly income range in the chart above.. Signature (Parent/Legal Guardian must sign or Student if own legal guardian) I certify the information provided above is true and accurrate to the best of my knowledge. I understand that school officials may check the provided information. X (sign here) (print name) (date) 6 ECOT Application 2.23.2015.indd 7 2/23/2015 10:43:43 AM

DEMOGRAPHIC INFORMATION This information is required by the Ohio Department of Education. This information remains confidential and is used for statistical purposes only. Your cooperation is greatly appreciated. 1) Is the student of Hispanic, Latino or Spanish origin? Yes No 2) If Yes or No to question 1, what is the student s race? (please check one or more of the following): W White B Black or African American A Asian I American Indian or Alaskan Native P Native Hawaiian or Other Pacific Islander I refuse to identify my childs race(see note below) **Please note: It is your right to refuse to identify your child s race, but the school is required to report your child s race to the federal government for statistical purposes; if you refuse to identify your child s race, ECOT will follow its procedures based on federal requirements and will make a determination on your childs race. This may cause your application to be pended. 3) Was this student born in the United States or its territories? Yes No If No to question 3, please provide date student first enrolled in U.S. schools: (MM/DD/YYYY) 4) Has this student ever been enrolled in ESL (English as Second Language)/ELL (English Language Learner) classes at a prior school (for help learning the English language)? Yes No 5) Did this student take the Ohio Test of English Language Acquisition (OTELA) at the previous school (This only applies for Limited English Proficient (LEP) students)? Yes No 6) Does this student s legal guardian speak English? Yes No UNITED STATES MILITARY & COLLEGE/UNIVERSITY CONSENT AND OPT OUT When requested, ECOT is required to provide the United States Military and colleges (if requested) with the name, address and telephone number of your child UNLESS you opt out of providing this information. We are also obligated to provide the same information to institutions of higher learning upon request, unless you opt out of providing this information. If this section is not filled out, ECOT will supply the information to the United States Military and colleges/universities as required under federal law. If the student is over the age of 18, the student must sign below in order to opt out of providing this information. I do not want my child s personal information provided to the military I do not want my child s personal information provided to colleges and universities X Signature (parent/guardian if under 18) Print Name Date 7 ECOT Application 2.23.2015.indd 8 2/23/2015 10:43:44 AM

EMERGENCY MEDICAL AUTHORIZATION FORM Student Full Name (Please Print) - - Social Security (optional) In the event your child needs to be treated medically for an emergency, please list any facts concerning your child s medical history that the Emergency Medical Technicians or Emergency Room Personnel should be aware of in order to care for your child. This includes information such as medication(s) currently being taken and allergies: I hereby give consent for Dr. (physician) Phone: to administer any treatment deemed necessary to my child or, in the event of the unavailability of this physician, or a medical emergency, treatment in the closest Emergency Center or Hospital. I hereby give consent for Dr. (dentist) Phone: to provide necessary dental treatment for my child in the event of an emergency. I decline above procedures for emergency care. My request for emergency medical treatment is: By signing the Authorization For Enrollment Form (page 10), I give consent to the above information. This form does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring the necessity for such surgery, are obtained prior to the performance of surgery. 8 ECOT Application 2.23.2015.indd 9 2/23/2015 10:43:44 AM

CONSENT FOR RELEASE OF RECORDS PLEASE SEND RECORDS TO: ECOT - Attn: Student Services 3700 South High St, Suite 95 Columbus, OH 43207 888-326-8395 (phone) 614-492-8894 (fax) Special Education Fax: (614) 643-7710 Student Full Name:(Please Print) Grade Date of Birth: Is the student currently enrolled in a school? Yes No Current/Most Recent School Attended: District: Dates Attended (month/year) / to / School Address: City: State: Zip: School Phone: ( ) IMPORTANT This form must be filled out completely for admittance into ECOT. ECOT will send this form to student s former school(s) following admission to ECOT. Do not submit this form directly to your school. Has the student ever used a Where was the student attending different last name? Yes No school the first week of October 2013? Public School Charter School Private/Parochial School Home School Program Other Previous School Name: Previous School City & State: Dates Attended (mo/yr): / to / Public School Charter School Private/Parochial School Home School Program Other SECTIONS BELOW ARE FOR HIGH SCHOOL STUDENTS ONLY: Last school attended for 8th grade: City and State of School: Dates Attended (mo/yr): / to / Public School Charter School Private/Parochial School Home School Program Other If the student is attending a career center or JVS, will they continue attending while at ECOT? Yes 1) Has the student taken the Ohio Graduation Test (OGT)? Yes No No Please check the sections student has passed: Reading Writing Math Science Social Studies 2) Please list when and where the OGT was taken: School Name City State Zip Date Tested With the understanding that the district is responsible for the confidentiality of educational information disclosed, I authorize the school(s) listed above or any other school the student has attended to release educational information regarding the student named above. X Parent/Guardian Signature (or student if own guardian) Date Address City/State/Zip In accordance with section 3313.672 of the Ohio Revised Code, ECOT will notify a law enforcement agency if all educational records are not received in fourteen days. Custody papers must be presented within sixty days. Please advise us immediately if the records will not be forthcoming. The above named student is enrolling in the Electronic Classroom of Tomorrow (ECOT). Please forward the following information to ECOT. 9 ECOT Application 2.23.2015.indd 10 2/23/2015 10:43:44 AM

AUTHORIZATION FOR ENROLLMENT & WITHDRAWAL FROM CURRENT SCHOOL PLEASE READ THE ADMISSIONS GUIDE BEFORE YOU FILL OUT THIS FORM. The authorized parent or legal guardian is hereby requesting admission to the Electronic Classroom of Tomorrow (ECOT). Parent/Guardian signature authorizes the School District of Residence to withdraw this student from his/her current school of enrollment effective the date the student logs in to ECOT. Students are expected to notify their local school district (if they have not done so already) that they reside within the district. ECOT is a community school established under Chapter 3314 of the Revised Code. The school is a public school and students enrolled in and attending the school are required to take State Achievement tests and other examinations prescribed by law. In addition, there may be other requirements for students at the school that are prescribed by law. Students who have been excused from the compulsory attendance law for the purpose of home education as defined by the Administrative Code shall no longer be excused for that purpose upon their enrollment in a community school. For more information about this matter, contact the school administrator or the Ohio Department of Education. The responsible party signing below, hereby certifies that they are authorized to enroll this student in ECOT, certifies the accuracy of all information provided, and certifies the authenticity of the copies of all documents provided with this enrollment application (including birth certificate, proof of residency, custody papers, Social Security card, immunization records and special needs or gifted documentation). ECOT is NOT a supplemental program. By completing this registration form, students have formally selected ECOT over any other public school. As the parent/guardian, I agree to provide transportation and/or accommodations to and from ECOT sites for required state tests and all other mandated tests. I understand that purchasing school supplies including computer paper and ink are my or my child s responsibility. I understand that opportunities for face-to-face meetings between my child and his/her teacher(s) will be made available several times per year at various ECOT-designated locations throughout the state. I have designated or will designate an adult to supervise my child s education. I have reviewed the entire enrollment application and the ECOT Admissions Guide and agree to abide by all the policies of ECOT including those policies and procedures contained within. I have read and understand the Technology and Communications Use Policy and release ECOT from liability to the extent authorized by the law. I understand the student s use, misuse, or abuse of the equipment and technology is my responsibility as the parent/guardian and I am responsible for the replacement cost of $700 for all ECOT computer equipment not returned within 10 days of separation from ECOT or which is returned damaged. I have read the Testing and Attendance Policy on page 5 of the Admissions Guide. I acknowledge and understand the Testing and Attendance policy statement. I also understand I may be withdrawn from ECOT if I do not complete all required state tests. *ALL PAGES OF THE APPLICATION ARE REQUIRED TO BE RETURNED FOR ADMISSION TO ECOT X X Student Signature Student Name (Print) Date Parent/Guardian Signature Parent/Guardian Name (Print) Date (or student if own guardian) - - Parent/Guardian Social Security (optional) Parent/Guardian Date of Birth 10 ECOT Application 2.23.2015.indd 11 2/23/2015 10:43:44 AM

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