Enrollment Forms Packet (EFP)

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1 Enrollment Forms Packet (EFP) Based on r student(s) grade and applicable circumstances, complete one enrollment package and review the information below to determine what should submit for each student seeking admission to the Insight School of Ohio (ISOH). You can fax, scan and , or mail the required paperwork. Important Note: Please send copies, do not mail the original documents Fax (preferred): Scan and Mail: Insight School of Ohio Required For? Item Description? Required for all Required for all rising 1st -9th Grade Required for all rising 10-12th Grade Required for that have an IEP or other Special Education needs Required for students that have a 504 plan Proof of Age Proof of Residency Immunization Record Education Rights Statement Release of Records Official Birth Certificate (not the hospital issued certificate) Two forms of Proof of Residency: Home Utility bill showing current address OR Mortgage/Rental statement including signature page showing Legal Guardian s name. Current Immunization Record. Please complete this form and submit. By filling out this form, are giving our school permission to request r student s official records from their previous school after the approval process. If r child is enrolling in Kindergarten or was Homeschooled please indicate it on the form, fill out the top portion and sign it. Provided in Provided in Emergency Medical Authoriztation Form Please complete this form and submit Provided in Report Card Transcripts IEP Evaluation Team Report 504 Accommodation Plan The most recent Report Card, except for students always homeschooled. You will need to request an unofficial transcript from r student s current school, which will show r student s academic standing. This is required in order to place all 10th through 12th graders. Once r student is approved, we will receive the official transcript directly from the school. A copy of r student s current IEP (Individualized Education Plan). Because the IEP expires yearly, please submit the current IEP. The Evaluation Team Report is valid for 3 years. If do not have a copy of r student s ETR, please obtain a copy from r student s current school. A copy of r student s current 504 Accommodation Plan. Because the 504 expires yearly, please submit the current 504.

2 CONSENT FOR RELEASE OF RECORDS PLEASE SEND RECORDS TO: ISOH - Attn: Records 33 North Third Street, Ste 620 Columbus, OH Fax: Student Information Insight School of Ohio IMPORTANT - This form must be filled out completely for admittance into ISOH. ISOH will send this form to the student s former school(s) following admission to ISOH. Do not submit this form directly to r school. Student s Full Name: first middle last Student s Date of Birth: Student s Legal Address: street apt # city county state zip Home Phone: Last School Attended Mobile Phone: Name of School: School s Address: street city state zip school district School s Phone: School s Fax: Does student receive Special Education Services? o Yes o No Is student enrolling in Kindergarten? o Yes o No PLEASE SUBMIT THE FOLLOWING: Official Transcript Standardized Test Scores Immunization Records Birth Certificate Copy of last report card Disciplinary records (including weapons violations) Custody Documentation (If applicable) Special Education Records (if applicable) Including, IEP, ETR, or 504 plan and any report period psychological reports, evaluation reports, etc. Other: Sign and Date below Name of Parent or Legal Guardian: first last Parent/Guardian s Signature: Please note: Parental permission is NOT required when records are requested by authorized school personnel. (Family Educational Rights and Privacy Act, Final Rules of Educational Records, Federal Register, June 17, 1976, VOL. 118, Page 24673)

3 EMERGENCY MEDICAL AUTHORIZATION FORM Student Name Telephone Address Purpose To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under school authority, when parents or guardians cannot be reached. Residential Parent or Guardian: Mother's Name Father's Name Other's Name Relationship to Other PART I OR II MUST BE COMPLETED PART I TO GRANT CONSENT I hereby give consent for the following medical care providers and local hospital to be called: Doctor Dentist Medical specialist Local Hospital Emergency Room Phone 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 doctor, 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. Facts concerning the child's medical history including allergies, medications being taken, and any physical impairments to which a physician should be alerted: Date Signature of Parent/Guardian Address PART II REFUSAL TO CONSENT I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the school authorities to take the following action Date Signature of Parent/Guardian Address

4 Education Rights Statement Student s Legal Name: last first middle Date of Birth: I attest that I am legally authorized to make any educational decisions for the above named student, including conferences with the child s teachers or any other educational authorities, granting permission for the child participation in school trips and other activities, and making any other decisions and executing any documents pertinent to their education. I understand that I am responsible for providing legal documentation to support the above statement. Legal Guardian Print Name: Legal Guardian Signature: Relationship to student: Student s Name: Student s Home Phone: 12

5 Waiver to Decline Receipt of Computer Every child enrolled in the Insight School of Ohio is entitled to receive a computer for their use while enrolled in the program. If choose to decline the computer for r student(s) enrolled in the Insight School of Ohio, will need to complete the form below and submit the form to the Insight School of Ohio. If while enrolled in the Insight School of Ohio change r mind and wish to have a computer ordered for the child, please contact r teacher immediately. NOTE: K12 Tech Support is unable to troubleshoot the computer problems of r own computer. ORC Section (A)(1): Each child enrolled in an e-school is entitled to a computer provided by the e-school; however, the parent may waive the entitlement. Complete the sentence below if choose to decline the computer for r student:(please print the names below) I would like to decline the computer for. (guardian s name) (student s name) Please sign and date affirming r decision as it is recorded above. Parent/Guardian s Signature: Student s Name: Student s Home Phone: 13

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