FAUQUIER COUNTY PUBLIC SCHOOLS Policy: Adopted: 04/10/12 Revised: 02/10/14, 08/11/14, 07/13/15 SCHOOL ADMISSIONS

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1 1. Persons to Whom an Education in the Fauquier County Public Schools Shall be Free 1.1. Consistent with Article VIII, Section 1 of the Constitution of Virginia, no person may be charged tuition for admission or enrollment in Fauquier County Public Schools, whether on a full-time or part-time basis, who meets the residency criteria set forth in Virginia Code Section and under Reside below No person of school age shall be charged tuition for enrollment in a general education development or alternative program offered as a regional or division-wide initiative by the local school division in which such person is deemed to reside pursuant to Virginia Code Section and under Reside below. 2. Definitions 2.1. Bona Fide Resident (Resident) - An individual shall be deemed a bona fide resident of the Fauquier County School Division when he or she has a physical residency in the County with the intent to make it a fixed and permanent home and is not residing in the County solely for the purpose of obtaining school privileges. Further, any change in residence must be bona fide and at a minimum the following conditions must exist: The original residence must be abandoned by the entire family The entire family must abandon the residence and take with them the household goods The change in residence must be made with the intent that it is permanent Before making a determination that an individual is not a bona fide resident of the Fauquier County School Division, the superintendent or his/her designee shall provide such person with notice and an opportunity to present all related evidence in support of his or her establishment of bona fide residence. The superintendent or his/her designee may refuse free admission of any individual to a public school of the Fauquier County School division unless he/she determines that the individual is a resident or is otherwise qualified to attend in accordance with this policy Non-Resident - A non-resident pupil is one who is not a resident student of the Fauquier County School Division in accordance with the terms of this policy, but who attends or proposes to attend a Fauquier County Public School Displaced Fauquier Resident - An individual who becomes a non-resident during the school year. The superintendent may permit attendance tuition-free for the remainder of the semester or term for students who become non-residents during that term or semester Future Fauquier Resident - An individual who will become a resident during the school year. The superintendent may permit attendance tuition-free for students who will become residents of Fauquier County during the semester or term during which they will physically become residents. Proof of future residency (e.g. housing contract, rental agreement, etc.) is required. 3. Reside See Policy for information regarding athletic eligibility residency requirements. 3.1 A person of school age (i.e., a person who will have reached his fifth birthday on or before September 30 of the school year and who has not reached 20 years of age on before August 1 of the school year) is eligible for admission on a non-tuition basis if residing in the Fauquier County School Division, or if eligible for admission 1

2 as a homeless person pursuant to this policy. School officials may not inquire into the student s citizenship or visa status in determining eligibility for tuition-free enrollment in Fauquier County Public Schools. A person with a disability who has reached the age of two (2) years on or before September 30 th of the school year and who has not reached the age of twenty-two (22) years and who has been determined to be eligible for a program of special education is considered to be of school age and eligible to attend Fauquier County Public Schools A person of school age shall be deemed to reside in the school division: When the person is living with a natural parent, a parent by legal adoption, or a legal guardian as determined by court documentation, in the Fauquier County School Division. The student is presumed to be a resident student, even if the parent is not the custodial parent under a property settlement agreement or divorce decree; No person of school age shall be denied admission or charged tuition when (i) such person's custodial parent has been deployed outside the United States as a member of the Virginia National Guard or as a member of the United States Armed Forces; and (ii) such person's custodial parent has executed a Special Power of Attorney under Title 10, United States Code, 1044b providing for the care of the person of school age by an individual who is defined as a parent in Virginia Code Section during the time of his deployment outside the United States. The person of school age shall be allowed to attend a school in the school division in which the individual providing for his care, pursuant to the Special Power of Attorney under Title 10, United States Code, 1044b, resides. Furthermore, when practicable, such persons of school age may continue to attend school in the Virginia school division they attended immediately prior to the deployment and shall not be charged tuition for attending such division; 3.3. When the parents of such person are dead and the person is living with a person in loco parentis who actually resides within the school division; 3.4. When the parents of such person are unable to care for the person and the person is living, not solely for school purposes, with another person who resides in the school division and is (i) the court-appointed guardian, or has legal custody, of the person (ii) acting in loco parentis pursuant to placement of the person for adoption by a person or entity authorized to do so under ; or (iii) an adult relative providing temporary kinship care as that term is defined in The school division will require one or both parents and the relative providing kinship care to submit signed, notarized affidavits (a) explaining why the parents are unable to care for the person, (b) detailing the kinship care arrangement, and (c) agreeing that the kinship care provider or the parent will notify the school within 30 days of when the kinship care arrangement ends, as well as a power of attorney authorizing the adult relative to make educational decisions regarding the person. The school division will require the parent or adult relative to obtain written verification from the department of social services where the parent or parents live, or from both that department and the department of social services where the kinship provider lives, that the kinship arrangement serves a legitimate purpose that is in the best interest of the person other than school enrollment. If the kinship care arrangement lasts more than one year, a school division will require continued verification directly from one or both departments of social services as to why the parents are unable to care for the person and that the kinship care arrangement serves a legitimate purpose other than school enrollment When the person is living with a parent, guardian, or person in loco parentis in a temporary shelter in the school division, not solely for school purposes; 3.6. When the person is living in the school division not solely for school purposes, as an emancipated minor; or 2

3 3.7. When the person has been placed in a foster care placement within the school division by a local social services agency, upon joint determination of the placing social services agency and the school division that such attendance is in the best interest of the child. No person of school age who is the subject of a foster care placement will be charged tuition regardless of whether the child is attending the school in which she or he was enrolled prior to the most recent foster care placement or is attending a school in the receiving school division Any individual who resides within the School Division and is beyond school age (who has reached his/her 20th birthday on or before August 1 of the school year) may, at the discretion of the School Board, be admitted into Fauquier County Public Schools. Such individuals may be charged tuition at the discretion of the School Board Certain other students may be admitted into the public schools of the division and may be charged tuition in accordance with section of the Code of Virginia and pursuant to Fauquier County School Board regulations No child of a person on active military duty attending a school free of charge in accordance with this policy shall be charged tuition by the school division upon such child's relocation to military housing located in another school division in the Commonwealth, pursuant to orders received by such child's parent to relocate to base housing and forfeit his military housing allowance. Such children shall be allowed to continue attending school in the school division and shall not be charged tuition for attending such school. Such children shall be counted in the average daily membership of the school division in which they are enrolled. Further, the school division in which such children are enrolled subsequent to their relocation to base housing shall not be responsible for providing for their transportation to and from school Parents or guardians must show proof of residency at the time of enrollment or at any time there is a change in residence. A combination of at least two forms of proof of residency must be provided. Examples of acceptable documents include a housing contract, rental agreement, property tax bill, utility bill and a homeowners or renters insurance policy. If the family is not designated as homeless and is living at a residence and cannot provide a lease or rental agreement, (for example if the family is living with a relative or friend or on the property of an employer), a notarized statement from the resident that the family is residing in the home plus the resident s proof of residency is required. If the family cannot show proof of residency, then they will be required to complete the Request for Out-of-County Tuition Status Form and pay tuition until such time proof of residency can be shown Parents or guardians may be required to provide additional verification of residency at the request of the division superintendent or designee if the superintendent has reason to question the validity of a family s residency documentation. 4. Additional Admission Requirements 4.1. A Student Data Form must be completed for enrollment An enrolling pupil must be accompanied by the person with whom he/she lives, unless such individual is an emancipated minor; either a natural parent, or a court-appointed legal guardian or legal custodian, or a person acting in loco parentis. The accompanying adult will be required to present verification of identity with official photo identification An individual other than a pupil s natural parent will be required to provide official proof of custody or guardianship, unless such individual is temporarily acting in loco parentis pursuant to Acceptable proof of custody is a certified copy of an Order of custody or guardianship issued by a Virginia court, or by another state or country, or a copy of a special power of attorney. 3

4 4.4. Except as otherwise provided below, no pupil shall be admitted for the first time to any public school in any school division in Virginia unless the person enrolling the pupil presents, upon admission, a certified copy of the pupil's birth record. The principal or his designee shall record the official state birth number from the pupil's birth record into the pupil's permanent school record and may retain a copy in the pupil's permanent school record. If a certified copy of the pupil's birth record cannot be obtained, the person so enrolling the pupil shall submit an affidavit setting forth the pupil's 4.5. age and explaining the inability to present a certified copy of the birth record. If the school division cannot ascertain a child's age because of the lack of a birth certificate, the child shall nonetheless be admitted into the public schools if the division superintendent determines that the person submitting the affidavit presents information sufficient to estimate with reasonable certainty the age of such child If a certified copy of the birth record is not provided, the administration shall immediately notify the local law enforcement agency. The notice to the local law-enforcement agency shall include copies of the submitted proof of the pupil's identity and age and the affidavit explaining the inability to produce a certified copy of the birth record Within 14 days after enrolling a transfer student, the administration shall request documentation that a certified copy of the pupil's birth record was presented when the pupil was enrolled in the former school The Department of Education shall develop a system of unique student identification numbers. The School Board shall assign such a number to each student enrolled in a public elementary school or secondary school. No student identification number shall include or be derived from the student s federal social security number. Each student shall retain his student identification number for as long as he is enrolled in a public elementary or secondary school in the Commonwealth Tuition rates are established each year in accordance with the provisions of of the Code of Virginia Prior to admission to the Fauquier County Public School Division, the parent, guardian, or other person having control or charge of the child shall provide, upon registration, a sworn statement or affirmation, indicating whether the student has been expelled from school attendance at a private school or in a public school division of the Commonwealth or another state for an offense in violation of school board policies relating to weapons, alcohol or drugs, or for the willful infliction of injury to another person. This document shall be maintained as a part of the student s scholastic record; and a sworn statement or affirmation indicating whether the student has been found guilty of or adjudicated delinquent for any offense listed in subsection G of Va. Code or any substantially similar offense under the laws of any state, the District of Columbia, or the United States or its territories. This document shall be maintained by the superintendent and by any others to whom he disseminates it, separately from all other records concerning the student. However, if the school administrators or the school board takes disciplinary action against a student based upon an incident which formed the basis for the adjudication of delinquency or conviction for an offense listed in subsection G of , the notice shall become a part of the student's disciplinary record When the child is registered as a result of a foster care placement, the information required under this subsection must be furnished by the local social services agency or licensed child-placing agency that made the placement A student, who has been expelled or suspended for more than thirty days from attendance at school by a school board or a private school in Virginia or in another state or for whom admission has been withdrawn by a private 4

5 school in Virginia or another state may be excluded from attendance in the Fauquier County School Division regardless of whether such student has been admitted to another school division or private school in Virginia or in another state subsequent to such expulsion, suspension, or withdrawal of admission upon a finding that the student presents a danger to the other students or staff of the school division after (i) written notice to the student and his/her parent that the student may be subject to exclusion, including the reasons therefore, and notice of the opportunity for the student or his parent to participate in a hearing to be conducted by the superintendent or his designee regarding such exclusion; and (ii) a hearing of the case has been conducted by the superintendent or his/her designee; and the decision has been to exclude the student from attendance. The student or his parent may file a written petition for review with the School Board within 15 days of notice of the decision of the superintendent or his/her designee. If the School Board grants a review of the record, the decision of the superintendent or his/her designee may be altered. Upon the expiration of the exclusion period for an expulsion or a withdrawal of admission, which period shall be established by the School Board, committee thereof, or superintendent or his designee, as the case may be, at the relevant hearing, the student may petition the School Board for readmission. If the petition for readmission is rejected, the School Board shall identify the length of the continuing exclusion period and the subsequent date upon which such student may petition the School Board for readmission. For the purposes of this section, the division superintendent s designee shall be the Assistant Superintendent for Student and Special Education Services or a professional employee within the administrative offices of the school division who reports directly to the division superintendent and who is not a school-based instructional or administrative employee. In excluding any such expelled student from school attendance, the School Board may accept or reject any or all of any conditions for readmission imposed upon such student by the expelling school board pursuant to Va. Code The excluding School Board shall not impose additional conditions for readmission to school This policy does not preclude contractual arrangements between the Fauquier County School Board and agencies of the federal government or the school board of another jurisdiction to permit students not otherwise eligible to attend Fauquier County Public Schools Prior to admission, the student must document compliance with, or eligibility for exemption from, the physical examination and immunization requirements contained in , and of the Code of Virginia and regulations 7-2.3(B) and 7-2.3(C) If the person enrolling a child who has been placed in foster care by a local social services agency is unable to produce a report of a comprehensive physical examination and/or proof of immunization, the student shall be immediately enrolled; however, the person enrolling the child shall provide a written statement that, to the best of his knowledge, the student is in good health and is free from communicable or contagious disease. In addition, the placing social service agency shall obtain and produce the required documents or otherwise ensure compliance with the statutory requirements for the foster child within 30 days after the child s enrollment. 5. Admission of Homeless Children 5.1. The Fauquier County School Board is committed to educating homeless children and youth. The division superintendent or his designee shall develop guidelines for contacting shelter agencies, ministerial associations, and other community service providers to identify homeless children within the school division. Such children shall be provided with educational services, including specialized services to meet their needs, as determined and directed by the division superintendent or his designee and in accordance with state and federal law. 5

6 5.2. Requirements The school division will serve each homeless student according to the student s best interest and will: continue the student s education in the school of origin for the duration of homelessness; and a student who becomes homeless between academic years or during an academic year, or for the remainder of the academic year if the student becomes permanently housed during an academic year; or enroll the student in any public school that non-homeless students who live in the attendance area in which the student is actually living are eligible to attend In determining what is in the best interest of a homeless student, the School Board shall: 5.3. Enrollment to the extent feasible, keep the student in the school of origin, except when doing so is contrary to the wishes of the student s parent or guardian; provide a written explanation, including a statement regarding the right to appeal as described below, to the homeless student s parent or guardian, if the school division sends the student to a school other than the school of origin or a school requested by the parent or guardian; and in the case of an unaccompanied youth, ensure that the school division s homeless liaison assists in placement or enrollment decisions regarding the student, considers the views of such unaccompanied youth, and provides notice to such youth of the right to appeal, described below The school selected in accordance with this regulation shall immediately enroll the homeless student, even if the student is unable to produce records normally required for enrollment, such as previous academic records, birth records, medical records, proof of residency, or other documentation The enrolling school shall immediately contact the school last attended by the student to obtain relevant academic and other records If the student needs to obtain immunizations, or immunization, birth, or medical records, the enrolling school shall immediately refer the parent or guardian of the student to the school division s homeless liaison, who shall assist in obtaining necessary immunizations, or immunization, birth, or medical records If the documentation regarding the comprehensive physical examination required for admission cannot be furnished for a homeless child or youth, and the person seeking to enroll the pupil furnishes to the school division an affidavit stating that the documentation cannot be provided because of the homelessness of the child or youth and also indicating that, to the best of his or her knowledge, such pupil is in good health and free from communicable or contagious disease, the school division shall immediately refer the student to the local school division homeless liaison who shall, as soon as 6

7 practicable, assist in obtaining the necessary physical examination by the local health department or other clinic or physician s office and shall immediately admit the pupil to school The decision regarding placement shall be made regardless of whether the student lives with the homeless parents or has been temporarily placed elsewhere Enrollment Disputes If a dispute arises over school selection or enrollment in a school: 5.5. Appeal Process the homeless student shall be immediately admitted to the school in which enrollment is sought and provided all services for which he or she is eligible, pending resolution of the dispute; the parent or guardian of the student shall be provided with a written explanation of the school s decision regarding school selection or enrollment, including the rights of the parent, guardian or student to appeal the decision; the student, parent or guardian shall be referred to the school division s homeless liaison who shall carry out the appeal process as expeditiously as possible after receiving notice of the dispute; and in the case of an unaccompanied youth, the homeless liaison shall ensure that the youth is immediately enrolled in school pending resolution of the dispute Oral Complaint - In the event that an unaccompanied student or the parent or guardian of a student (hereinafter referred to as the Complainant) disagrees with a school s decision regarding the student s eligibility to attend the school, the Complainant shall orally present his position to the school division s homeless liaison Written Complaint - If the disagreement is not resolved within five (5) school days, the Complainant may present a written complaint to the homeless liaison. The written complaint must include the following information: (i) the date the complaint is given to the homeless liaison; (ii) a summary of the events surrounding the dispute; (iii) the name(s) of the school division personnel involved in the enrollment decision; and (iv) the result of the oral complaint to the homeless liaison Within five (5) school days after receiving the written complaint, the homeless liaison will reach a decision regarding the contested enrollment and shall provide a written statement of that decision, including the reasons therefore, to the Complainant. The liaison will inform the division superintendent of the formal complaint and its resolution Appeal to Division Superintendent - If the Complainant is not satisfied with the written decision of the homeless liaison, the Complainant may appeal that decision to the division superintendent by filing a written appeal. The homeless liaison shall ensure that the division superintendent receives copies of the written complaint and the response thereto. The division superintendent or his designee shall schedule a conference with the Complainant to discuss the complaint. Within five (5) school days of receiving the written appeal, the division superintendent, or his designee, shall provide a written decision to the Complainant, including a statement of the reasons therefore. 7

8 Appeal to the State - If the Complainant is not satisfied with the written decision of the Superintendent, the Complainant may appeal that decision within ten (10) business days from receipt of the written notice to the local homeless education liaison who will present the appeal to the Office of the State Coordinator of Homeless Education (Project HOPE-Virginia). The local homeless education liaison will maintain a file of written notification given to parents, guardians, or unaccompanied youth. The liaison will clarify the state-level decision making process. The State Coordinator or designee shall: 5.6. Comparable Services Review local School Division records to ensure proper procedures were followed and, based on the review of School Division records and consultation with Project HOPE- Virginia Advisory Board members, when appropriate, forward a recommendation to the Superintendent of Public Instruction regarding the appropriate placement for the student within five (5) work days of receiving the appeal The Assistant Superintendent of Special Education and Student Services, or designee, will make the final determination. The family or unaccompanied youth, the local School Division(s), the Director of Student Services, and Project HOPE-Virginia will be informed by the State Superintendent of Public Instruction of the final disposition within ten (10) business days of receiving the case and recommendation from the State Coordinator for Homeless Education Project HOPE-Virginia staff will provide technical assistance to the School Division, as needed, to comply with final determination Project Hope-Virginia staff will follow-up with the School Division thirty (30) business days after the final disposition by the Assistant Superintendent of Special Education and Student Services to determine the status of the child or youth s enrollment Each homeless student shall be provided services comparable to services offered to other students in the school attended by the homeless student, including the following: 5.7. Transportation transportation services; educational services for which the student meets the eligibility criteria, such as services provided under Title I, educational programs for children with disabilities, and educational programs for students with limited English proficiency; programs in vocational and technical education; programs for gifted and talented students; and school nutrition programs At the request of the parent or guardian (or in the case of an unaccompanied youth, the homeless liaison), transportation will be provided for a homeless student to and from the school of origin as follows: 8

9 5.8. Definitions If the homeless child or youth continues to live in the area served by the school division in which the school of origin is located, the child s or youth s transportation to and from the school of origin shall be provided or arranged by the school division in which the school of origin is located If the homeless child s or youth s living arrangements in the area served by the school division in which the school of origin is located terminate and the child or youth, though continuing his or her education in the school of origin, begins living in an area served by another school division, the school division of origin and the school division in which the homeless child or youth is living shall agree upon a method to apportion the responsibility and costs for providing the child with transportation to and from the school of origin. If the school divisions are unable to agree upon such method, the responsibility and costs for transportation shall be shared equally The terms homeless student, homeless child, and homeless youth mean an individual who lacks a fixed, regular, and adequate nighttime residence, and include: children and youth, including unaccompanied youth who are not in the physical custody of their parents, who are sharing the housing of other persons due to loss of housing, economic hardship, or other causes; are living in motels, hotels, trailer parks, or camping grounds due to the lack of alternative adequate accommodations or in emergency, congregate, temporary or transitional shelters; are abandoned in hospitals; or are awaiting foster care placement; have a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings; or are living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations, or similar settings; AND migratory children who qualify as homeless for the purposes of this policy and regulation because the children are living in circumstances described above The term migratory children means children who are, or whose parents or spouses are, migratory agricultural workers, including migratory dairy workers or migratory fishermen, who, in the preceding 36 months, have moved from one school division to another in order to obtain, or accompany such parent or spouse in order to obtain, temporary or seasonal employment in agriculture or fishing The term school of origin means the school that the student attended when permanently housed or the school in which the student was last enrolled The term unaccompanied youth includes a youth not in the physical custody of a parent or guardian. 9

10 6. Admission of Nonpublic Students for Part-Time Enrollment 6.1. The Fauquier County School Board acknowledges the provisions for equivalent instruction under Virginia law. The Board further observes that equivalent or "acceptable alternative" home or private school instruction is not the same as the education delivered in the public school system The families of non-enrolled students in grades 9-12 who wish to enroll their students on a part-time basis in the Fauquier County Public Schools may be eligible to do so for participation in classes and/or certain student activities. Students in grades K-8 are not permitted to enroll in Fauquier County Public schools on a part-time basis The Superintendent shall develop regulations necessary to provide for part-time enrollment of high school students in cases where the admission of non-enrolled students will have little/no impact on the admitting school s programs and/or services. 7. Non-Residents 7.1. Special Attendance Situations 8. Tuition Basis Upon a determination that the applicant qualifies for admission to the Fauquier County Public Schools and that space is available in the grade level and/or education program for which the applicant is qualified, the Superintendent or his/her designee may admit the following persons into the public schools of the Division in accordance with the criteria and conditions specified below: 8.1. The following individuals may be admitted, and except as otherwise specifically provided herein, the payment of tuition and other charges calculated in accordance with paragraph 8 of this policy shall be required as a condition of admission: Persons who reside within the school division but who are not of school age Persons of school age who are residents of the Commonwealth but who do not reside within the school division, except as provided in this section Persons of school age who are attending school in the school division pursuant to a foreign student exchange program approved by the school board Persons of school age who reside beyond the boundaries of the Commonwealth but near thereto in a state or the District of Columbia which grants the same privileges to residents of the Commonwealth Persons of school age who reside on a military or naval reservation located wholly or partly within the geographical boundaries of the school division and who are not domiciled residents of the Commonwealth of Virginia; however, no person of school age residing on a military or naval reservation located wholly or partly within the geographical boundaries of the school division may be charged tuition if federal funds provided under P.L. 874 of 1950, commonly known as Impact Aid, shall fund such students at not less than 50 percent of the total per capita cost of education, exclusive of capital outlay and debt service, for elementary or secondary pupils, as the case may be, of such school division Persons of school age who, as domiciled residents of the Commonwealth who were enrolled in a public school within the school division, are required as a result of military or federal orders issued to 10

11 9. Non-Tuition Basis their parents to relocate and reside on federal property in another state or the District of Columbia, if the school division subsequently enrolling such persons is contiguous to such state or District of Columbia Persons of school age who reside in the school division and who are enrolled in summer programs, exclusive of required remediation as provided in Virginia Code :1, or in local initiatives or programs not required by the Standards of Quality or the Standards of Accreditation The Superintendent may admit the following individuals without requiring the payment of tuition, in accordance with the criteria and conditions below: An individual who is attending school in the Fauquier County School Division pursuant to a foreign student exchange program approved by the School Board An individual who is a non-resident of the School Division and who has been placed in foster care or other custodial care or in an orphanage or other children s home, child-caring institution, or group home located within the geographical boundaries of the Fauquier County School Division under circumstances which qualify for reimbursement to the Fauquier County School Division of the cost of educating the individual in accordance with Code of Virginia, section The Fauquier County School Board will consider the application of anyone interested in attending Fauquier County Public Schools. However, eligibility for consideration does not signify acceptance of the admission application of a student. Each application for admission will be considered on an individual basis. The Superintendent may promulgate regulations necessary to implement this policy Foreign students in an F-1 immigration status or who obtain F-1 student visas shall not be admitted in the Division s elementary schools or publicly funded adult education programs. Such students may be admitted, for a period up to twelve (12) months, in the Division s secondary schools only if they prepay the full, unsubsidized per capita cost of the education. 10. Procedure for Admission The following procedure shall be followed for application and review of applications for admission of nonresident students. An applicant for admission under this policy shall be deemed qualified if the applicant meets the applicable school age requirements and can participate in the program and activities of the School Division with or without reasonable accommodation that does not impose undue hardship on the School Division. In addition, the applicant shall be legally authorized to enter and remain in the United States and to attend school Access to the Fauquier County Public School shall not be denied to any qualified applicant based upon race, sex, religion, color, creed, nationality, or disability A parent or guardian of a non-resident student shall apply for admission on behalf of his child by completing the school division application. The application form shall contain information and agreements including, but not limited to: The current legal residence of the child and the school division in which he is currently enrolled; 11

12 The child s social security number, if applicable; The basis for requesting admission; The specific building and grade level (elementary) or course offerings (secondary) in which the student desires to be enrolled if accepted by the school division; and, The agreement that the student becomes subject to all policies, regulations and guidelines of the school division, including the Fauquier County Student Code of Conduct Superintendent s Designee s Review Within five (5) administrative days of receipt of the application, the Superintendent s designee shall provide written notification of the approval or denial If the application is denied, the parent or guardian may appeal the decision by sending a written request with additional justification to the Superintendent s designee within five (5) administrative days of notification. The Superintendent s designee shall respond in writing to the appeal within three (3) administrative days If the appeal is denied, the Superintendent s designee shall notify the parent or guardian that they may make a written request to the Superintendent s designee for a Superintendent s conference within three (3) administrative days of receiving the decision of the Superintendent s designee A failure to make a written request for an appeal within the timelines specified shall constitute a waiver of the opportunity for appeal and the decision of the Superintendent s designee shall be final Superintendent s Conference 11. Tuition The Superintendent shall schedule a conference within five (5) administrative days of the request. The requesting party and Superintendent s designee will be invited to attend the conference. At this conference, the Superintendent shall review the record of the Request for Out-of-County Tuition Status. Further, the Superintendent may hear from the requesting party and the Superintendent s designee. Within three (3) administrative days of the conference, the Superintendent shall issue a decision granting or denying the Request for Out-of-County Tuition Status The decision of the Superintendent is final After approval of application, the parent must complete school enrollment papers and meet the additional admission requirements Tuition charged pursuant to this policy shall be equivalent to the total per capita cost of education, exclusive of capital outlay and debt service. However, if the tuition charge is payable by the School Board of the School Division of the student s residence pursuant to a contract entered into between the two (2) School Boards, the tuition charge shall be that fixed by such contract Payment of tuition shall be in advance and continued access to programs and activities of the School Division shall be subject to the payment of all fees and charges. 12

13 12. Transportation Transportation shall not be furnished to non-resident students except in those cases where: 13. Contracts Agreements between Divisions specify transportation services; or Federal or state legislation mandates the provision of transportation services; or Transportation services can be provided at no cost to the Division This policy does not preclude contractual arrangements between the Fauquier County School Board and agencies of the federal government or the School Board of another jurisdiction to permit students who are not otherwise eligible to attend Fauquier County Public Schools. 14. Special Exceptions School Division/County Government Employees - In implementing this policy, the Superintendent may make a special exception for the admission of children of Fauquier County School Division and Fauquier County Government employees who are non-residents of Fauquier County under the following circumstances: Children of non-residents employed by the Fauquier County School Division and the Fauquier County Government may be eligible for this special exception while the parent is a full-time, permanent employee of the Fauquier County School Division or the Fauquier County Government. Such children shall be enrolled in the school that serves the geographical zone for the school or facility in which the child s parent is assigned to work. For the purposes of this exception, school bus drivers and aides are considered full-time, permanent employees Such non-resident employees who elect to place their children in Fauquier County Public Schools will not be charged a tuition cost, so long as the child or children are residents of Virginia The parent shall be responsible for the child s transportation to and from school For purposes of this special exception, the term parent shall include legal guardian. LEGAL REFERENCE: Code of Virginia, 1950, as amended, , , , , , , , , , , :1, , , , , , , , , , , , , , ; , and ; Public Law , Illegal Immigrations Reform and Immigrant Responsibility Act of 1996, 625; Steward B. McKinney Homeless Assistance Act, Subtitle VII-B (P.L ); Immigration and Nationality Act, as amended, 8 U.S.C 1101, et seq.; 8 CFR Parts 1 499; and 22 CFR Parts Regulations and Forms Follow 13

14 ACCOMPANYING REGULATIONS/FORMS REGULATION (A) REGULATIONS FOR ADMISSION OF NON-PUBLIC SCHOOL STUDENTS FOR PART-TIME ENROLLMENT; APPLICATION REGULATION (B) STUDENT IMMUNIZATIONS REGULATION (C) PHYSICAL EXAMINATIONS OF STUDENTS FORM 7-2.3F1 FORM 7-2.3F1S FORM 7-2.3F2 FORM (A)F1 FORM (A)F2 FORM (A)F3 FORM (B)F1 FORM (B)F2 STUDENT ENROLLMENT FORM SPANISH STUDENT ENROLLMENT FORM REQUEST FOR OUT OF COUNTY TUITION STATUS APPLICATION FOR PART-TIME ENROLLMENT (GRADES 9-12) AFFIDAVIT PENDING CERTIFIED COPY OF BIRTH CERTIFICATE CRIMINAL CONVICTION, JUVENILE DELINQUENCY ADJUDICATION, AND HISTORY OF EXPULSION AFFIRMATION SCHOOL ENTRANCE HEALTH FORM CERTIFICATE OF IMMUNIZATIONS CERTIFICATE OF RELIGIOUS EXEMPTION IMMUNIZATIONS Regulations and Forms Follow 14

15 REGULATION (A) REGULATIONS FOR ADMISSION OF NON-PUBLIC SCHOOL STUDENTS PART-TIME ENROLLMENT FOR 1. Admission 1.2. Parents shall identify their children as private school or home school students who desire part-time enrollment in academic courses of study. Students admitted under this policy shall be designated as part-time students Students admitted under this regulation must be residents of Fauquier County. 2. Enrollment 2.1. The parent/guardian of non-enrolled students in grades 9-12 may enroll students on a part-time basis in the Fauquier County Public Schools for participation in a maximum of two classes per school term. Part-time students must enroll in the full length of the course Students may participate in a co-curricular activity which is directly related to the class in which they are enrolled. 3. Procedures Part-time students shall participate in co-curricular activities which are required as a result of enrollment in certain classes (orchestra, band, chorus, drama, etc.) Part-time students may participate in optional co-curricular activities which are directly related to the class in which they are enrolled (Spanish Club, Math Club, Art Club, etc.) Part-time students may not participate in extra-curricular activities, such as those sponsored by the Virginia High School League (athletics, cheerleading, Theatre Festival, etc.) A Part-Time Enrollment application (see attached) must be submitted to the principal of the attending school by July 1 for first term and December 1 for second term The school principal will review this application and determine availability of space based upon: Locally adopted maximum students per class: no more than 24 in English and 25 in other courses The number of students enrolled as of August 1 in each class plus five (5) students to allow for growth If the proposed part-time enrollment would result in the purchase of additional equipment or the employment of additional staff, the request shall be forwarded to the Superintendent. The Superintendent may request additional funding The school principal will forward a copy of the application to the Superintendent with a recommendation for approval or denial of the request for part-time enrollment, based on criteria stated above The Superintendent will approve or deny the request based on the principal s recommendation and/or the conditions referenced above. 1

16 4. Conditions 4.1. Part-time enrollment is determined annually and there will be no guarantee that it will be continued from one year to the next Part-time students shall abide by all the policies and regulations of Fauquier County Public Schools. These policies include, but are not limited to, the Code of Conduct, the completion of all coursework in a satisfactory manner, and the attendance policy. The parent or guardian will be required to sign the Code of Conduct and accept liability for any property damage done by the student. Violation of rules and regulations will be cause for the Superintendent to review participation of the student in any program/activity, and could result in immediate dismissal Part-time students must meet equivalent pre-requisite requirements to be enrolled in a course Class ranking and grade point average shall not be computed for part-time enrolled students, and such students shall not be eligible to graduate or receive a diploma from the Fauquier County Public Schools Part-time enrolled students shall not participate in activities other than those which are specified in 2.3 (excluded activities include prom and field trips related to enrolled course) Transportation to and from school will be the responsibility of the family. Those admitted under this policy will be subject to the same rules and fees regarding parking as fully enrolled students Full time students will be given first consideration for parking on the high school campus Part-time students, when attending classes in the public schools, must sign in and out of the school by following the building level procedure Part-time students are to be present on school grounds only when their selected course/activity is in session. It is the responsibility of the part-time student to be aware of any changes in the schedule during inclement weather or for other reasons Part-time students must take all required tests in a course, including state end-of-course tests. 5. Restrictions 5.1. The parent/guardian of non-enrolled students in grades K-8 may not enroll students on a part-time basis in Fauquier County Public Schools nor may non-enrolled students in grades K-8 participate in co- or extracurricular activities. 2

17 REGULATION 7-2.3(B) STUDENT IMMUNIZATIONS 1. Generally 1.1. Before entering a Fauquier County public school for the first time, every pupil shall furnish a certificate confirming that the pupil has been immunized against communicable diseases as required by , and of the Code of Virginia, has begun receiving the first series of all such vaccinations, or is exempt as provided elsewhere in this regulation. Any parent, guardian, or other person having control or charge of a child being home instructed or exempted or excused from school attendance shall comply with state immunization requirements. 2. Immunization Requirements 2.1 Diphtheria and Tetanus Toxoids and Pertussis Vaccine (DPT, DTaP, Tdap) A minimum of 3 doses. A child must have at least one dose of DTaP or DTP vaccine on or after the fourth birthday. If the child has received six doses of DTaP or DTP before the fourth birthday, additional doses are contraindicated. DT (Diphtheria, Tetanus) vaccine is required for children who are medically exempt from the pertussis containing vaccine (DTaP or DTP). Adult Td is required for children seven (7) years of age and older who do not meet the minimum requirements for tetanus and diphtheria. Effective July 1, 2006, a booster dose of acellular pertussis vaccine shall be administered prior to entry into the sixth grade Measles, Mumps, Rubella (MMR) Vaccine A minimum of two (2) measles, one (1) mumps, and one (1) rubella. (Most children receive two (2) doses of each because the vaccine usually administered is the combination vaccine MMR). First dose must be administered at age 12 months (365 days) or older. If first dose is administered before 12 months of age, the dose does not count and must be repeated. Second dose of measles vaccine does not have to be administered until age four (4) six (6) years (usually at entry to kindergarten) but can be administered at any time after the minimum interval between dose one (1) and dose two (2). The minimum interval is four (4) weeks (28 days) Haemophilus Influenza Type b (Hib) Vaccine* This vaccine is required ONLY for children up to 60 months of age. A primary series consists of either two (2) or three (3) doses (depending on the manufacturer) followed by a booster dose at age months. However, the child's current age and not the number of prior doses received govern the number of doses required. Unvaccinated children between the ages of 15 and 60 months are only required to have one dose of vaccine Hepatitis B Vaccine A complete series of three (3) doses of hepatitis B vaccine is required for all children. However, the FDA has approved a two (2)-dose schedule ONLY for adolescents years of age AND ONLY when the Merck Brand (RECOMBIVAX HB) Adult Formulation Hepatitis B Vaccine is issued. The two (2) RECOMBIVAX HB Adult doses must be separated by a minimum of four (4) months. If the three (3)-dose hepatitis B vaccine schedule is used, there should be at least one (1) month spacing between the 1st and 2nd doses and four (4) months spacing between the 1st and 3rd doses Pneumococcal (PCV) Vaccine One (1) to four (4) doses, dependent on age at first dose, of pneumococcal conjugate vaccine for children up to 60 months of age Polio Vaccine - A minimum of three (3) doses of all IPV or all OPV polio vaccine. If a child has had only three doses of polio vaccine, one dose must have been administered on or after the fourth birthday. However, a child who has received four (4) doses of any combination of IPVor OPV polio vaccine before the fourth birthday is adequately immunized and does not need a dose after the fourth birthday. 1

18 2.7. Varicella Vaccine (Chickenpox) All children born on and after January 1, 1997, shall be required to have a dose of chickenpox vaccine not earlier than the age of 12 months (365 days) Human Papillomavirus (HPV) Vaccine Three (3) doses of properly spaced HPV vaccine for females. The first dose shall be administered before the child enters the sixth grade. NOTE: The four (4)-day grace period for administration of vaccines does not apply to MMR vaccine or Varicella vaccine. 3. Conditional Enrollment 3.1. A student may be enrolled for a period of 90 school days contingent upon the student's having received at least one dose of each of the required vaccines and the student's possessing a plan, from a physician, registered nurse or employee of a local health department, for completing his immunization requirements within the ensuing 90 school days; except that a student who has not yet received a second dose of measles (rubeola) vaccine must receive such second dose pursuant to the Virginia Board of Health s minimum immunizations required for school attendance. The admitting official shall, at the end of the conditional enrollment period, exclude any student who is not in compliance with the immunization requirements and who has not been granted an exemption, until that student provides documentary proof that his/her immunization schedule has been completed, unless documentary proof that a medical contraindication developed during the conditional enrollment period is submitted. 4. Exemptions 1. When the parent or guardian has an objection on the grounds that the administration of immunizing agents conflicts with his religious tenets or practices and provides the principal with a written statement of such objection, unless an emergency or a disease epidemic has been declared by the Virginia Board of Health. 2. When the parent or guardian presents a statement from a physician or a local health department that states that the physical condition of the child is such that the administration of one or more of the required immunizing agents would be detrimental to the health of the child. 5. Homeless Students 5.1. If a student is a homeless child or youth as defined in Va. Code Section and does not have documentary proof of necessary immunizations or has incomplete immunizations and is not exempted from immunization, the School Division will immediately admit such student and will immediately refer the student to the local School Division homeless liaison who will assist in obtaining the documentary proof of, or completing, immunization. 6. Evidence of Immunization 6.1. Evidence acceptable for proof of required immunizations must include the month, day, and year each dosage was administered on forms developed by or approved by the Virginia Department of Health. All students for whom immunization dates cannot be provided (month, day, year) must be referred to the local health department or their private physicians to update their records before entering school. 7. Transfer of Records 7.1. The admitting official of every school shall be responsible for sending a student s immunization records or a copy thereof, along with his/her permanent academic or scholastic records, to the admitting official of the school to which a student is transferring within 30 days of his/her transfer to the new school. 2

19 8. Report of Student Immunization Status 8.1. Each admitting official shall, within 30 days of the beginning of each school year or entrance of a student, or by October 15 of each school year, file with the State Health Department through the health department for his/her locality, a report summarizing the immunization status of the students in his/her school. This report shall be filed on Form SIS, the Student Immunization Status report, and shall contain the number of students admitted with a medical or religious exemption and the number of students who have been conditionally admitted. 9. Penalties 9.1. Any student who fails to provide documentary proof of immunization in the manner prescribed, within the time periods provided, shall be excluded from school attendance by the school s admitting official Any student exempted from immunization requirements shall be excluded from school attendance for his/her own protection until the danger has passed, if the commissioner so orders such exclusion upon the identification of an outbreak, potential epidemic, or epidemic of a vaccine-preventable disease in that student s school Any person, willfully violating or refusing, failing or neglecting to comply with any regulation order of the Board of Commissioner of any provision of the Code of Virginia shall be guilty of a Class 1 misdemeanor, unless a different penalty is specified. 3

20 REGULATION 7-2.3(C) PHYSICAL EXAMINATIONS OF STUDENTS 1. Physical Examinations and Reports 1.1. Before any child is admitted for the first time to any public preschool, kindergarten, or elementary school (grades K-6), such child must furnish a report from a qualified licensed physician or a licensed nurse practitioner acting under the supervision of a licensed physician, of a comprehensive physical examination of a scope as prescribed by the Virginia Health Commissioner, performed within the twelve (12) months prior to the date such child first enters kindergarten or elementary school. At the end of such report shall summarize abnormal physical findings, if any, and shall specifically state what, if any, conditions are found that would identify the child as disabled A copy of such report must be presented to the school on the child's behalf The report must indicate that the child has received the physical examination no earlier than 12 months prior to the date of first entering kindergarten or elementary school Transfer students entering a Fauquier County elementary school must provide one of the following: Records establishing that a physical examination was completed prior to enrolling in another school (evidence of such an examination may be: (a) a copy of the report of the medical examination or (b) transcript notation or phone verification from the other school with records to follow); OR A report of a physical examination dated within the last 12 months Physical examination reports shall be placed in the child's health record at the school A physical examination shall not be required of any child whose parent or guardian objects on religious grounds and who shows no visible evidence of sickness. The parent or guardian shall state in writing that, to the best of his knowledge, the child is in good health and free from any communicable or contagious disease The school division shall coordinate with the Fauquier County Department of Health to conduct physical examinations for medically indigent children, upon request, before their admission to any kindergarten or elementary school, without charge to the children or their parents or guardians Parents/guardians of students entering school shall complete a health information form as required by state law. (See attached). Such forms shall be returned within fifteen (15) days of receipt unless reasonable extensions have been granted by the superintendent or his designee. Failure to return the form as required by state law may result in the child's exclusion from school; however, no child who is a homeless child or youth as defined in subdivision six (6) of Virginia Code , shall be excluded from school for failure to complete such form. Forms Follow 1

21 7-2.3F1 Revised 3/21/2017 Date: FAUQUIER COUNTY PUBLIC SCHOOLS INITIAL ENROLLMENT FORM Has This Student Ever Attended Fauquier County Public Schools? Yes No Has This Student Ever Attended School In Virginia? Yes No For Office Use Only: School: Student ID#: Entry Date: Entry Code: IEP/504: Grade: Student is not military connected. Student is a dependent of a member of the Active Duty Forces (full time) Army, Navy, Air Force, Marines, or Coast Guard, the Commissioned Corps of the Nat l Oceanic & Atmospheric Admin., or the Commissioned Corps of the U.S. Public Health Services. Reserve; student is a dependent of a member of the Reserve Forces (Army, Navy, Air Force, Marine Corps, or Coast Guard) National Guard, active or reserve duty; student is a dependent of a member of the National Guard (and not a dependent of a member of the U.S. Armed Forces.) Last Name: Student Information (Section A) First Name: 1 Middle Name: Nickname: Gender: Male Female Birth Certificate Number: Date of Birth: Place of Birth: City/County: State: Country: Race/Ethnicity Please Answer Questions 1 and 2 as Instructed Below*: 1. Is The Student Hispanic or Latino? (Choose Only One.) No, Not Hispanic or Latino Yes, Hispanic or Latino 2. What Is the Student s Race? (Choose One Or More.) American Indian or Alaskan Native White Native Hawaiian or Other Pacific Islander Black or African American Asian *The Federal Government Requires the Use of Observer Identification of Elementary and Secondary School Students Race and Ethnicity, as a Last Resort, if Such Information Is Not Provided by the Students and Their Parents or Guardians. Did This Student Attend Kindergarten? Yes No Has Student Repeated Any Grade? Yes No If So, Which Grade(s)? Last Grade Completed Name of Last School Attended: Address: Date of Withdrawal from Last School: Home Schooled Grade Level(s): Has the Student Ever Been Eligible for Special Education Services? Yes No Is the Student Currently Eligible for Special Education Services? Yes No Does the Student Currently have a 504 Plan? Yes No Is the Student Currently Receiving Gifted Services? Yes No Has your child ever received ESL services? Yes No Newly Enrolled Kindergarten Students Only (Section B) Did This Student Attend Preschool? Yes No If yes, pick the PK experience code that applies. 1 Head Start 2 Public Preschool 3 Private Preschool/Daycare 7-2.3F1 Revised 3/21/2017

22 7-2.3F1 Revised 3/21/2017 FAUQUIER COUNTY PUBLIC SCHOOLS INITIAL ENROLLMENT FORM 4 Dept. of Defense Child Development Program 5 Family Home Daycare Provider 6 No Preschool Experience How many hours per week was the child in preschool or cared for by a home provider? Select one: 0 No time in a formal or institutional PK program. 1 Less than 15 hours per week or more but less than 30 hours per week or more hours per week. Was the PK experience in Fauquier County? Yes No Student Address (Section C) Street Address: City: Zip Code: Home/Main Number: Mailing Address (if Different Than Street Address): If the Student Does Not Reside with the Parent or Guardian, Provide the Name of Person with Whom the Student Resides: Relationship of Person to Student: Parent Information (Section D) Father s LEGAL Name: Mother s LEGAL Name: Father s Date of Birth: Mother s Date of Birth: Street Address (If Different from Student): Street Address (If Different from Student): Mailing Address (If Different from Street Address): Mailing Address (If Different from Street Address): Occupation: Employer: Business Telephone: Cell/Pager: Occupation: Employer: Business Telephone: Cell/Pager: Are You the Legal Guardian of This Student? Are You the Legal Guardian of This Student? Yes No Yes No Please check this box if there are any court documents specifying guardianship or limitations of which the school must be aware, e.g., legal guardian, limited parental visitation, or pick up, severed parental educational rights. These documents will need to be provided to the school. Legal Guardian (If Other Than Parent) (Section E) Name(s): Telephone Number: Occupation: Business Telephone: Cell/Pager: Employer: Foster Information (Section F) Telephone: Foster Placing Agency: Agency Location: Foster Parent Name(s): Cellular: Case Worker Name: Case Worker Telephone: Sibling Information: (Section G) Last Name First Name Middle Name Date Of Birth F1 Revised 3/21/2017

23 7-2.3F1 Revised 3/21/2017 FAUQUIER COUNTY PUBLIC SCHOOLS INITIAL ENROLLMENT FORM Complete This Box To Reflect Your Child s Current Living Situation: (Section H) (Your Answer May Enable the Student to Receive Additional Services Under the McKinney-Vento Assistance Act.) Check One Box That Best Describes the Student s Living Situation: In Permanent Home with Parent or Guardian With Relative or Others Due to Lack of Housing In a Motel/Hotel or Other Similar Situation Due to Lack of Alternative, Adequate Housing In a Shelter At a Park or in a Car Temporarily Housed in a Shelter Awaiting Department of Social Services Permanent Foster Placement. Youth Not Living With a Parent or Guardian Other Situation with No Fixed Address (Specify): Residency Certification (Section I) Per Code of Virginia , It Is a Class 4 Misdemeanor to Make a False Statement As to Residency. Making a False Statement Regarding Residency May Incur Liability for Tuition as a Non-Resident Student and/or Court Imposed Fines. Please Complete Either Option A, B, C, or D: A. This Is to Certify That, for Whom Enrollment Is Requested in Fauquier County Public Schools, Resides According to the Fauquier County Public Schools Policy, Within the Boundaries of the School Zone. B. This Is to Certify That, for Whom Enrollment Is Requested in Fauquier County Public Schools, Does Not Reside Within the Boundaries of the School Zone and a Special School Zone Request Was Granted for the Current School Year. C. This Is to Certify That, for Whom Enrollment Is Requested in Fauquier County Public Schools, Does Not Reside Within the Boundaries of Fauquier County and Request for Out-of-County Tuition Status Has Been Granted for the Current School Year. D. This Is to Certify That, for Whom Enrollment Is Requested in Fauquier County Public Schools, Does Not Presently Have a Fixed and Regular Nighttime Residence, Has Requested to Be Allowed to Enroll Pursuant to Policy, and Has Completed Section H. Fauquier County Public Schools Shall Be Free to Each Person of School Age Who Resides Within the County of Fauquier. Tuition Is Regularly Charged to Other Persons Requesting Admission. A False Certification May Result in Legal Action to Recover Tuition Charges. Signature of Parent or Guardian Date Completed with the assistance of: Signature Date F1 Revised 3/21/2017

24 7-2.3F1 Revised 3/21/2017 FAUQUIER COUNTY PUBLIC SCHOOLS INITIAL ENROLLMENT FORM For Office Use Only To the Principal: According to FCPS Policy, Two Proof of Residency Documents Are Required: At Least One at the Time of Initial Enrollment and a Second Within 30 Days of Enrollment. Please Check the Types of Proof Provided: Housing Contract Rental Agreement/Letter from Owner or Landlord. (Must Be Notarized.) Property Tax Bill Utility Bill (Cellular Telephone Bills Are Not Accepted.) A Driver s License Is Not Acceptable Proof of Residency. In Lieu of the Proof of Residency Documents, The Documents Required In Option D Above May Be Accepted. Signature of Principal or Designee Date An Inspection of Your Child s Records Is Available upon Request. Distribution: Initial Enrollment Form Should Be Kept In Permanent Cumulative File. Do Not Purge F1 Revised 3/21/2017

25 7-2.3F1S Revised 3/21/2017 Date/Fecha: FAUQUIER COUNTY PUBLIC SCHOOLS INITIAL ENROLLMENT FORM FORMULARIO INICIAL DE MATRICULACIÓN Has This Student Ever Attended Fauquier County Public Schools? El estudiante asistió anteriormente a las Escuelas Públicas del Condado de Fauquier? Yes/Sí No ENGLISH/SPANISH For Office Use Only: School: Student ID#: Entry Date: Entry Code: IEP/504: Grade: Has This Student Ever Attended School In Virginia? El estudiante asistió anteriormente a alguna escuela pública en el Estado de Virginia? Yes/Sí No Student is not military connected./ El estudiante no tiene conexiones militares. Student is a dependent of a member of the Active Duty Forces (full time) Army, Navy, Air Force, Marines, or Coast Guard, the Commissioned Corps of the Nat l Oceanic & Atmospheric Admin., or the Commissioned Corps of the U.S. Public Health Services. El estudiante es un dependiente de un miembro en Servicio Activo (a tiempo completo) de las Fuerzas Armadas, Navales, Aéreas, Infantería de Marina o Guardia Costera, o de funcionarios que pertenezcan al Cuerpo de Comisión de Servicios de la Administración Nacional Oceánica y Atmosférica o al Cuerpo de Comisión de Servicios de la Salud Pública. Reserve; student is a dependent of a member of the Reserve Forces (Army, Navy, Air Force, Marines, or Coast Guard) La Reserva; el estudiante es un dependiente de un miembro de las Fuerzas de Reserva (Fuerzas Armadas, Naval, Aérea, Infantería de Marina o Guardia Costera. National Guard, active or reserve duty; student is a dependent of a member of the National Guard (and not a dependent of a member of the U.S. Armed Forces.) Guardia Nacional, en servicio activo o reserva; el estudiante es un dependiente de un miembro de la Guardia Nacional (y no es un dependiente de un miembro de las Fuerzas Armadas de los Estados Unidos. Last Name/Apellido: Student Information (Section A)/ (Sección A) Información sobre el estudiante First Name/Primer nombre: Middle Name/Segundo nombre: Nickname/Apodo: Gender/Sexo: Male/Masculino Female/ Femenino Birth Certificate Number/ Número de certificado de nacimiento : Date of Birth/Fecha de nacimiento: Place of Birth/Lugar de nacimiento: State/Estado: Country/País: City/County/Ciudad/Condado: Race/Ethnicity Please Answer Questions 1 and 2 as Instructed Below*: Raza/Grupo étnico Por favor responda a las preguntas 1 y 2 tal como se indica a continuación**: 1. Is The Student Hispanic or Latino? (Choose Only One.) /El estudiante es hispano o latino? (Sólo marque una) No, Not Hispanic or Latino/ No, no es hispano o latino Yes, Hispanic or Latino/ Sí, es hispano o latino 2. What Is the Student s Race? (Choose One Or More.) / De qué raza es el estudiante? (Puede marcar más de una) American Indian or Alaskan Native/Indígena americana o nativa de Alaska White/Blanca Native Hawaiian or Other Pacific Islander /Nativa de Hawai u otra isla del Pacífico Black or African American /Negra o Afroamericana Asian/Asiática *The Federal Government Requires the Use of Observer Identification of Elementary and Secondary School Students Race and Ethnicity, as a Last Resort, if Such Information Is Not Provided by the Students and Their Parents or Guardians. **Si los padres o los tutores no proporcionan la información solicitada, el Gobierno Federal requiere que un observador determine la raza y el grupo étnico al que pertenece el estudiante de la escuela secundaria o primaria. Did This Student Attend Kindergarten? / Asistió el estudiante a Kinder? Yes/Sí No Has Student Repeated Any Grade?/ Repitió algún grado? Yes/Sí No If So, Which Grade(s)? Qué grado? Last Grade Completed/ Cuál fue el último grado que cursó?/ Name of Last School Attended /Nombre de la última escuela a la que asistió: Address/Dirección: Date of Withdrawal from Last School / Fecha en que dejó la última escuela: Home Schooled Grade Level(s) /Nivel o grado de la Instrucción Académica en Casa: Has the Student Ever Been Eligible for Special Education Services? Alguna vez recibió servicios de Educación Especial? Yes/ Sí No Is the Student Currently Eligible for Special Education Services? Está recibiendo servicios de Educación Especial en este momento? Yes/Sí No F1S Revised 3/21/2017

26 7-2.3F1S Revised 3/21/2017 ENGLISH/SPANISH FAUQUIER COUNTY PUBLIC SCHOOLS INITIAL ENROLLMENT FORM FORMULARIO INICIAL DE MATRICULACIÓN Does the Student Currently have a 504 Plan? Tiene actualmente un Plan 504? Yes/Sí No Is the Student Currently Receiving Gifted Services? Está recibiendo servicios del Programa de Aptitud y Talento en este momento? Yes/Sí No Has your child ever received ESL services? Ha recibido alguna vez servicios de ESL? Yes/Sí No Newly Enrolled Kindergarten Students Only (Section B) (Sección B) Solo para Estudiantes Recientemente Matriculados a Kindergarten Did This Student Attend Preschool? / El estudiante asistió a un centro preescolar? Yes/ Sí No If yes, pick the PK experience code that applies./si respondió que Sí, marque la opción de PK que corresponda: 1 Head Start / Programa de Head Start 2 Public Preschool / Preescolar Público 3 Private Preschool/Daycare / Preescolar/Guardería Privada 4 Dept. of Defense Child Development Program / Programa del Desarrollo del Niño del Departamento de Defensa 5 Family Home Daycare Provider / Proveedor de Guardería o Cuidado de Niños en una Vivienda Familiar 6 No Preschool Experience / Sin Experiencia Preescolar. How many hours per week was the child in preschool or cared for by a home provider? Select one: Cuántas horas por semana asistía al preescolar o estaba a cargo de un cuidador(a) en un hogar? Marque solo una: 0 No time in a formal or institutional PK program/ No asistió a ninguna institución o programa formativo preescolar. 1 Less than 15 hours per week / Menos de 15 horas por semana or more but less than 30 hours per week/ Más de 15 horas pero menos de 30 horas por semana or more hours per week/ 30 horas o más por semana. Was the PK experience in Fauquier County? / Asistió a un centro preescolar en el Condado de Fauquier? Yes/ Sí No Student Address (Section C) / (Sección C) Dirección del estudiante Street Address/Dirección: City/Ciudad: Zip Code / Código postal: Home/Main Number/ Número de teléfono principal: Mailing Address (if Different Than Street Address)/Dirección postal si es diferente de la dirección donde reside: If the Student Does Not Reside with the Parent or Guardian, Provide the Name of Person with Whom the Student Resides: Relationship of Person to Student: Si el Estudiante no reside con el Padre o Guardián, escriba el nombre de la persona con quien reside: Relación de la Persona con el Estudiante: Parent Information (Section D)/ (Sección D) Información de los padres Father s LEGAL Name/Nombre LEGAL del padre: Mother s LEGAL Name/Nombre LEGAL de la madre: Father s Date of Birth/Fecha de nacimiento del padre: Street Address (If Different from Student)/Dirección si es diferente a la del estudiante: Mailing Address (If Different from Street Address) /Dirección Postal si es diferente a la de su residencia: Occupation/Ocupación: Employer/Empleador: Business Telephone/Teléfono del trabajo: Cell/Pager/Celular/Bíper: Mother s Date of Birth/Fecha de nacimiento de la madre: Street Address (If Different from Student) /Dirección si es diferente a la del estudiante: Mailing Address (If Different from Street Address) /Dirección Postal si es diferente a la de su residencia: Occupation/Ocupación: Employer/Empleador: Business Telephone/Teléfono del trabajo: Cell/Pager/Celular/Bíper: Are You the Legal Guardian of This Student? Es usted el tutor legal del estudiante? Yes/Sí No Are You the Legal Guardian of This Student? Es usted el tutor legal del estudiante? Yes/Sí No F1S Revised 3/21/2017

27 7-2.3F1S Revised 3/21/2017 ENGLISH/SPANISH FAUQUIER COUNTY PUBLIC SCHOOLS INITIAL ENROLLMENT FORM FORMULARIO INICIAL DE MATRICULACIÓN Please check this box if there are any court documents specifying guardianship or limitations of which the school must be aware, e.g., legal guardian, limited parental visitation, or pick up, severed parental educational rights. These documents will need to be provided to the school. Por favor marque la casilla si tiene documentos de la corte, que especifiquen la tutoría o limitaciones de las cuales la escuela debería tener conocimiento, p.ej., tutoría legal, visita o retiro limitado de los niños por parte de sus padres, derechos educativos excluídos de los padres. Legal Guardian (If Other Than Parent) (Section E) Sección E Tutor Legal (en caso de no ser el padre o la madre) Name(s)/Nombre(s): Cell/Pager/Celular/Bíper: Telephone Number/Número de teléfono: Occupation/Ocupación: Employer/Empleador: Business Telephone/Teléfono del trabajo: Foster Information (Section F)/ (Sección F) Información acerca del Hogar de Crianza Foster Parent Name(s)/ Nombre del padre o madre de crianza: Telephone/Teléfono: Cellular/Celular: Case Worker Name/Nombre del Asistente Social: Foster Placing Agency/Agencia encargada: Agency Location/Dirección de la agencia: Case Worker Telephone/ Teléfono del Asistente Social: Sibling Information: (Section G)/ (Sección G) Información de los hermanos: Last Name/ Apellido First Name/Primer Nombre Middle Name/Segundo Nombre Date Of Birth/Fecha de nacimiento Complete This Box To Reflect Your Child s Current Living Situation: (Section H) (Sección H) Llene el siguiente cuestionario acerca de la situación de vivienda actual de su hijo(a): (Your Answer May Enable the Student to Receive Additional Services Under the Mckinney-Vento Assistance Act.) (Sus respuestas permitirán establecer si el estudiante puede recibir servicios adicionales de acuerdo con la Ley de Asistencia McKinney-Vento) Check One Box That Best Describes the Student s Living Situation/Marque la opción (Sólo Una) que mejor describe la situación actual de vivienda del estudiante: In Permanent Home with Parent or Guardian/Vive en un hogar permanente con el padre y/o madre o tutor. With Relative or Others Due to Lack of Housing/Vive con parientes debido a que no tiene vivienda. In a Motel/Hotel or Other Similar Situation Due to Lack of Alternative, Adequate Housing/Vive en un motel/hotel u otro lugar similar por falta de una vivienda alternativa o adecuada. In a Shelter/Vive en un albergue o casa de refugio At a Park or in a Car/Vive en un parque o en un coche Temporarily Housed in a Shelter Awaiting Department of Social Services Permanent Foster Placement./Vive temporalmente en una casa de refugio esperando que el Departamento de Servicio Social lo ubique en un hogar de crianza. Youth Not Living With a Parent or Guardian/Joven que no vive con sus padres o tutor. Other Situation with No Fixed Address (Specify)/Otro tipo de arreglo de vivienda y sin domicilio fijo(explique): Residency Certification (Section I)/ (Sección I) Certificación de Residencia Per Code of Virginia , It Is a Class 4 Misdemeanor to Make a False Statement As to Residency. Making a False Statement Regarding Residency May Incur Liability for Tuition as a Non-Resident Student and/or Court Imposed Fines. Conforme al Código de Virginia , es un delito menor de clase 4 hacer una declaración falsa en cuanto a la residencia. Si hace una declaración falsa referente a su residencia, es posible que se sea responsable de pagar los gastos de instrucción como si fuera un estudiante no residente y los gastos que imponga el juez. Please Complete Either Section A, B, C, or D/Por favor llene la parte A, B, C o D: F1S Revised 3/21/2017

28 7-2.3F1S Revised 3/21/2017 ENGLISH/SPANISH FAUQUIER COUNTY PUBLIC SCHOOLS INITIAL ENROLLMENT FORM FORMULARIO INICIAL DE MATRICULACIÓN A. This Is to Certify That, for Whom Enrollment Is Requested in Fauquier County Public Schools, Resides According to the Fauquier County Public Schools Policy, Within the Boundaries of the School Zone. Certifico que a quien solicito se matricule en las Escuelas Públicas del Condado de Fauquier, reside dentro de los límites correspondientes a la escuela B. This Is to Certify That, for Whom Enrollment Is Requested in Fauquier County Public Schools, Does Not Reside Within the Boundaries of the School Zone and a Special School Zone Request Was Granted for the Current School Year. Certifico que a quien solicito se matricule en las Escuelas Públicas del Condado de Fauquier no reside dentro de los límites correspondientes a la escuela y se le ha otorgado un permiso especial (Special School Zone Request) por el corriente año escolar. C. This Is to Certify That, for Whom Enrollment Is Requested in Fauquier County Public Schools, Does Not Reside Within the Boundaries of Fauquier County and Request for Out-of-County Tuition Status Has Been Granted for the Current School Year. Certifico que a quien solicito se matricule en las Escuelas Públicas del Condado de Fauquier, no reside dentro de los límites del Condado de Fauquier y se le ha aprobado la solicitud para pagar una instrucción como un estudiante que vive fuera del condado, por el corriente año escolar. D. This Is to Certify That, for Whom Enrollment Is Requested in Fauquier County Public Schools, Does Not Presently Have a Fixed and Regular Nighttime Residence, Has Requested to Be Allowed to Enroll Pursuant to Policy, and Has Submitted a Student Residency Questionnaire. Certifico que a quien solicito se matricule en las Escuelas Públicas del Condado de Fauquier, actualmente no tiene una residencia permanente para pasar la noche y se solicita que se le permita matricular de acuerdo a los reglamentos establecidos y ha llenado y presentado un cuestionario de residencia (Student Residency Questionnaire). Fauquier County Public Schools Shall Be Free to Each Person of School Age Who Resides Within the County of Fauquier. Tuition Is Regularly Charged to Other Persons Requesting Admission. A False Certification May Result in Legal Action to Recover Tuition Charges. Las personas que viven dentro de los confines del Condado de Fauquier tendrán derecho a asistir a las Escuelas Públicas del Condado en forma gratuita. Se cobran los gastos de instrucción a otras personas que soliciten ser admitidas. Si usted hace una declaración falsa, es posible que iniciemos una acción judicial en su contra para recobrar los gastos de instrucción. Signature of Parent or Guardian/ Firma del padre, madre o tutor Date/Fecha Completed with the assistance of: / Nombre y firma de la persona que ayudó al Padre/Tutor a llenar el formulario: Signature/ Firma Date/Fecha For Office Use Only To the Principal: According to FCPS Policy, Two Proof of Residency Documents Are Required: At Least One at the Time of Initial Enrollment and a Second Within 30 Days of Enrollment. Please Check the Types of Proof Provided: Housing Contract Rental Agreement/Letter from Owner or Landlord. (Must Be Notarized.) Property Tax Bill Utility Bill (Cellular Telephone Bills Are Not Accepted.) A Driver s License Is Not Acceptable Proof of Residency. In Lieu of the Proof of Residency Documents, The Documents Required In Option D Above May Be Accepted. Signature of Principal or Designee Date An Inspection of Your Child s Records Is Available upon Request. Los expedientes de su hijo(a) están a su disposición si desea revisarlos pero debe solicitarlo en la oficina de la escuela. Distribution: Initial Enrollment Form Should Be Kept In Permanent Cumulative File. Do Not Purge F1S Revised 3/21/2017

29 7-2.3-F2 REQUEST FOR OUT-OF-COUNTY TUITION STATUS Name of student: School Year: Present address of student: Name of parent/guardian: Daytime phone: Are you a FCPS or FC employee: Yes No (If you answer yes, form 7-2.2F1 MUST accompany this form) Present address: Evening phone: Grade to attend: School Division previously attended: School: Under what circumstances did student leave? Is your child currently attending through a Special Request? Yes No If yes, first time applied: Are you requesting that the tuition be waived? Yes No Does your child participate in any of the following programs: Gifted ESL Special Education Reason for special request: PARENT S SIGNATURE NOTE: Students are subject to all policies, regulations, and guidelines of the School Division, including the Code of Conduct. REQUESTED SCHOOL OF ATTENDANCE SECTION It is the principal s recommendation that this request be approved. Yes No Principal s comments (if any): PRINCIPAL S SIGNATURE DATE DATE CENTRAL OFFICE SECTION Out-of-County Request is approved for the school year indicated Yes No Tuition is charged in the amount of: Tuition is waived Per School Board Policy Other Central Office s comments (if any): Assistant Superintendent for Student & Special Education Services Date When all signatures have been obtained, a copy of this form will be sent to the school, parent & Budget & Planning Office. Original form will be filed in the Supt s Office. (Revised: 3/12)

30 7-2.3(A)F1 FAUQUIER COUNTY PUBLIC SCHOOLS Application for Part-Time Enrollment for Grades 9-12 School Year: Student s Name: Date of Birth: Address: Grade Entering: Parent/Guardian: Telephone No. (work) (home) Current Educational Placement: 1Home Schooled 1Religious Exemption 1Private School Specify: 1Charter School Specify: 1Other Specify: Educational Placement for Upcoming School Year: 1Home Schooled 1Religious Exemption 1Private School Specify: 1Charter School Specify: 1Other Specify: Classes (maximum of 2): 1) 2) (Attach assurance that all class prerequisites as outlined in the Program of Studies have been met including any assessment data and/or standardized testing.) First-Time Requests Must Include: 1Proof of Residency 1Birth Certificate and Social Security Number 1Immunization Records 1Expulsion/Long-Term Suspension Affidavit (JEC-F3) Signature of Parent/Guardian Date FOR OFFICE USE ONLY First Requested Class: 1Recommended 1Not Recommended Justification: Second Requested Class: 1Recommended 1Not Recommended Justification: Signature of Principal Date FOR SUPERINTENDENT/SCHOOL BOARD ONLY 1 Approved 1Denied Name Title Date A copy of the final recommendation should be duplicated and sent to the school and parent. One copy will be retained in the Superintendent s office.

31 AFFIDAVIT PENDING CERTIFIED COPY OF BIRTH CERTIFICATE 7-2.3(A)F2 REV. 6/1/2012, answers to the best of his/her personal knowledge, the following questions in his/her own handwriting on this page, asked by duly authorized officials of the Fauquier County Public Schools Division concerning a pupil s identity and age requesting enrollment as a pupil within the Division in accordance with Section of the Code of Virginia. 1. What is your name? 2. Have you been advised by an official of the Division, and do you understand that you are required to answer the questions contained in this Affidavit as a condition to your enrollment and admission of a pupil into the Division because of your inability to supply the Division with a certified copy of the pupil s birth record? 3. Do you understand that giving a false or otherwise untrue answer to any of the questions in this Affidavit could result in a criminal charge being brought against you? 4. Do you understand that when a question in this Affidavit asks if you have knowledge of or if you know of an instance or situation, it means that you are expected to relate any knowledge you may have about the incident, whether it be personal knowledge or information received from other people, and to relate the source of your knowledge and information? 5. What is the full name of the pupil you wish to enroll in this Division? 6. What is the age, date, and place of birth of the pupil being enrolled in this Division? 7. Who are the parents, parents by legal adoption, or person serving in loco parentis and responsible for the care of the pupil desired to be enrolled? 8. Do you have legal custody imposed by a court order or have you been designated court-appointed guardian for the pupil desired to be enrolled? What court entered such order and what type of case was it (i.e., custody hearing, etc.? 9. Why are you unable to present a certified copy of the birth records of the enrolling student? 10. What documentary (written) proof can be or is offered of the pupil s identity and age? (Attach same hereto.) 11. To the best of your knowledge, has this pupil ever been reported to any law enforcement agency as a missing child? If the response to question #11 is yes, identify by name and address the law enforcement agency and date of report. AFFIANT SIGNATURE NOTARIAL STATEMENT: I HEREBY CERTIFY THAT ON THIS DAY OF, IN FAUQUIER COUNTY, VIRGINIA, AND, PARENT(S)/LEGAL CUSTODIAN(S) OF THE ABOVE NAMED STUDENT, PERSONALLYAPPEARED BEFORE ME AND ACKNOWLEDGED THAT THE FOREGOIONG FACTS ARE TRUE AND CORRECT TO THE BEST OF HIS/HER KNOWLEDGE, INFORMATION AND BELIEF. NOTARY PUBLIC: NOTARY REGISTRATION NUMBER: MY COMMISSION EXPIRES:

32 AFFIDAVIT PENDING CERTIFIED COPY OF BIRTH CERTIFICATE 7-2.3(A)F2 REV. 6/1/ Birth certificates required upon admission; required notice to the local law-enforcement agency. A. Except as otherwise provided in this subsection, no pupil shall be admitted for the first time to any public school in any school division in this Commonwealth unless the person enrolling the pupil shall present, upon admission, a certified copy of the pupil s birth record. The principal or his designee shall record the official state birth number from the pupil s birth record into the pupil s permanent school record and may retain a copy in the pupil s permanent school record. If a certified copy of the pupil s birth record cannot be obtained, the person so enrolling the pupil shall submit an affidavit setting forth the pupil s age and explaining the inability to present a certified copy of the birth record. If the school division cannot ascertain a child s age because of the lack of a birth certificate, the child shall nonetheless be admitted into the public schools if the division superintendent determines that the person submitting the affidavit presents information sufficient to estimate with reasonable certainty the age of such child. However, if the student seeking enrollment is a homeless child or youth as defined in , the school shall immediately enroll such student, even if such student is unable to produce the records required for enrollment and shall immediate contact the school last attended by the student to obtain relevant academic and other records, and shall comply with the provisions of the federal McKinney- Vento Homeless Education Assistance Improvements Act of 2001, as amended (42 U.S.C et seq.), including immediately referring the parent of the student or the youth to the local school division liaison, as described in the federal Act, who shall assist in obtaining the necessary records for enrollment. B. Upon failure of any person enrolling a pupil to present a certified copy of the pupil s birth record, the principal of the school in which the pupil is being enrolled or his designee shall immediately notify the local law-enforcement agency. The notice to the local law-enforcement agency shall include copies of the submitted proof of the pupil s identify and age and the affidavit explaining the inability to produce a certified copy of the birth record. C. Within fourteen (14) days after enrolling a transferred pupil, the principal of the school in which the pupil has been enrolled or his designee shall request that the principal or his designee of the school in which the pupil was previously enrolled submit documentation that a certified copy of the pupil s birth record was presented upon the pupil s enrollment. D. Principals and their designees shall be immune from any civil or criminal liability in connection with any notice to a local law-enforcement agency of a pupil lacking a birth certificate or failure to give such notice as required by this section. (1990, c.295; 1991, c. 523; 2004, c 500; 2007, c. 49.)

33 FAUQUIER COUNTY PUBLIC SCHOOLS CRIMINAL CONVICTION, JUVENILE DELINQUENCY ADJUDICATION, AND HISTORY OF EXPULSION AFFIRMATION Section of the Code of Virginia requires that parents/guardians provide upon registration of students in public schools: (A)F3 REV. 6/1/ A sworn statement or affirmation indicating whether the student has been expelled from school attendance at a private school or in a public school division of the Commonwealth or in another state for an offense in violation of school board policies relating to weapons, alcohol or drugs, or for the willful infliction of injury to another person[et seq]. 2. A sworn statement or affirmation indicating whether the student has been found guilty of or adjudicated delinquent for any offense listed in subsection G of or any substantially similar offense under the laws of any state, the District of Columbia, or the United States or its territories[et seq]. C. ANY PERSON MAKING A MATERIALLY FALSE STATEMENT OR AFFIRMATION SHALL BE GUILTY UPON CONVICTION OF A CLASS 3 MISDEMEANOR. These offenses include but may not be limited to: A firearm offense Arson and related crimes Homicide Burglary and related offenses Felonious assault and bodily wounding Robbery Criminal sexual assault Prohibited street gang participation Manufacture, sale, gift, distribution or possession of Schedule I or II controlled substances Manufacture, sale or distribution of marijuana Recruitment of other juveniles for criminal street gang activity Prohibited street gang activity Student Name: Date of Birth: Parent/Legal Guardian Affirmation: I affirm that the above student has not been expelled from school attendance at a private school or in a public school division of the Commonwealth or in another state or the District of Columbia for an offense listed above or any substantially similar offense. I affirm that the above student has not been found guilty of or adjudicated delinquent for an offense listed above or any substantially similar offense under the laws of any state, the District of Columbia, or the United States or its territories. I affirm that the above student has been expelled from school attendance at a private school or in a public school division of the Commonwealth or in another state or the District of Columbia for an offense listed above or any substantially similar offense. Name and Location of Expelling School/Division: Date of Expulsion: Reason for Expulsion: I affirm that the above student has been found guilty of or adjudicated delinquent for an offense listed above or any substantially similar offense under the laws of any state, the District of Columbia, or the United States or its territories. Type of Offense Date of Offense Jurisdiction Where Offense Occurred (PARENT SIGNATURE AND NOTARY STATEMENT ON REVERSE - PAGE 2)

34 FAUQUIER COUNTY PUBLIC SCHOOLS CRIMINAL CONVICTION, JUVENILE DELINQUENCY ADJUDICATION, AND HISTORY OF EXPULSION AFFIRMATION (A)F3 REV. 6/1/2012 PARENT/GUARDIAN SIGNATURE DATE PRINTED PARENT/GUARDIAN NAME NOTARIAL STATEMENT: I HEREBY CERTIFY THAT ON THIS DAY OF,, IN FAUQUIER (DAY) (MONTH) (YEAR) COUNTY, VIRGINIA, AND, PARENT(S)/LEGAL (PARENT(S)/LEGAL GUARDIAN(S) NAMES(S) CUSTODIAN(S) OF THE ABOVE NAMED STUDENT, PERSONALLY APPEARED BEFORE ME AND ACKNOWLEDGED THAT THE FOREGOING FACTS ARE TRUE AND CORRECT TO THE BEST OF HIS/HER KNOWLEDGE, INFORMATION AND BELIEF. NOTARY PUBLIC: NOTARY REGISTRATION NUMBER: MY COMMISSION EXPIRES: 2

35 7-2.3(B)F1 03/02/17 COMMONWEALTH OF VIRGINIA SCHOOL ENTRANCE HEALTH FORM Health Information Form/Comprehensive Physical Examination Report/Certification of Immunization Part I HEALTH INFORMATION FORM State law (Ref. Code of Virginia ) requires that your child is immunized and receives a comprehensive physical examination before entering public kindergarten or elementary school. The parent or guardian completes this page (Part I) of the form. The Medical Provider completes Part II and Part III of the form. This form must be completed no longer than one year before your child s entry into school. Name of School: Current Grade: Student s Name: Last First Middle Student s Date of Birth: / / Sex: State or Country of Birth: Main Language Spoken: Student s Address: City: State: Zip: Name of Mother or Legal Guardian: Phone: - - Work or Cell: - - Name of Father or Legal Guardian: Phone: - - Work or Cell: - - Emergency Contact: Phone: - - Work or Cell: - - Condition Yes Comments Condition Yes Comments Allergies (food, insects, drugs, latex) Diabetes Allergies (seasonal) Head injury, concussions Asthma or breathing problems Hearing problems or deafness Attention-Deficit/Hyperactivity Disorder Heart problems Behavioral problems Lead poisoning Developmental problems Muscle problems Bladder problem Seizures Bleeding problem Sickle Cell Disease (not trait Bowel problem Speech problems Cerebral Palsy Spinal injury Cystic fibrosis Surgery Dental problems Vision problems Describe any other important health-related information about your child (for example, feeding tube, hospitalizations, oxygen support, hearing aid, etc.): List all prescription, over-the-counter, and herbal medications your child takes regularly: Check here if you want to discuss confidential information with the school nurse or other school authority. Yes No Please provide the following information: Name Phone Date of Last Appointment Pediatrician/primary care provider Specialist Dentist Case Worker (if applicable) Child s Health Insurance: None FAMIS Plus (Medicaid) FAMIS Private/Commercial/Employer sponsored I, (do ) (do not ) authorize my child s health care provider and designated provider of health care in the school setting to discuss my child s health concerns and/or exchange information pertaining to this form. This authorization will be in place until or unless you withdraw it. You may withdraw your authorization at any time by contacting your child s school. When information is released from your child s record, documentation of the disclosure is maintained in your child s health or scholastic record. Signature of Parent or Legal Guardian: Date: / / Signature of person completing this form: Date: / / Signature of Interpreter: Date: / / MCH 213 G revised 10/2010 1

36 COMMONWEALTH OF VIRGINIA SCHOOL ENTRANCE HEALTH FORM Part II - Certification of Immunization Section I To be completed by a physician or his designee, registered nurse, or health department official. See Section II for conditional enrollment and exemptions. A copy of the immunization record signed or stamped by a physician or designee, registered nurse, or health department official indicating the dates of administration including month, day, and year of the required vaccines shall be acceptable in lieu of recording these dates on this form as long as the record is attached to this form. Only vaccines marked with an asterisk are currently required for school entry. Form must be signed and dated by the Medical Provider or Health Department Official in the appropriate box. Student s Name: Date of Birth: Last First Middle Mo. Day Yr. IMMUNIZATION RECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN *Diphtheria, Tetanus, Pertussis (DTP, DTaP) *Diphtheria, Tetanus (DT) or Td (given after 7 years of age) *Tdap booster (6 th grade entry) 1 *Poliomyelitis (IPV, OPV) *Haemophilus influenzae Type b (Hib conjugate) *only for children <60 months of age *Pneumococcal (PCV conjugate) *only for children <2 years of age Measles, Mumps, Rubella (MMR vaccine) *Measles (Rubeola) 1 2 Serological Confirmation of Measles Immunity: *Rubella 1 Serological Confirmation of Rubella Immunity: *Mumps 1 2 *Hepatitis B Vaccine (HBV) Merck adult formulation used *Varicella Vaccine 1 2 Date of Varicella Disease OR Serological Confirmation of Varicella Immunity: Hepatitis A Vaccine 1 2 Meningococcal Vaccine 1 Human Papillomavirus Vaccine Other Other Other I certify that this child is ADEQUATELY OR AGE APPROPRIATELY IMMUNIZED in accordance with the MINIMUM requirements for attending school, child * care Required or preschool vaccine prescribed by the State Board of Health s Regulations for the Immunization of School Children (Minimum requirements are listed in Section III). Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.): / / Certification of Immunization 11/06 MCH 213 G revised 10/2010 2

37 Student s Name: Date of Birth: Section II Conditional Enrollment and Exemptions Complete the medical exemption or conditional enrollment section as appropriate to include signature and date. MEDICAL EXEMPTION: As specified in the Code of Virginia , C (ii), I certify that administration of the vaccine(s) designated below would be detrimental to this student s health. The vaccine(s) is (are) specifically contraindicated because (please specify):. DTP/DTaP/Tdap:[ ]; DT/Td:[ ]; OPV/IPV:[ ]; Hib:[ ]; Pneum:[ ]; Measles:[ ]; Rubella:[ ]; Mumps:[ ]; HBV:[ ]; Varicella:[ ] This contraindication is permanent: [ ], or temporary [ ] and expected to preclude immunizations until: Date (Mo., Day, Yr.):. Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.): RELIGIOUS EXEMPTION: The Code of Virginia allows a child an exemption from receiving immunizations required for school attendance if the student or the student s parent/guardian submits an affidavit to the school s admitting official stating that the administration of immunizing agents conflicts with the student s religious tenets or practices. Any student entering school must submit this affidavit on a CERTIFICATE OF RELIGIOUS EXEMPTION (Form CRE-1), which may be obtained at any local health department, school division superintendent s office or local department of social services. Ref. Code of Virginia , C (i). CONDITIONAL ENROLLMENT: As specified in the Code of Virginia , B, I certify that this child has received at least one dose of each of the vaccines required by the State Board of Health for attending school and that this child has a plan for the completion of his/her requirements within the next 90 calendar days. Next immunization due on. Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.): Section III Requirements For Minimum Immunization Requirements for Entry into School and Day Care, consult the Division of Immunization web site at Children shall be immunized in accordance with the Immunization Schedule developed and published by the Centers for Disease Control (CDC), Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP), otherwise known as ACIP recommendations (Ref. Code of Virginia (a)). (requirements are subject to change.) Certification of Immunization 10/2010 MCH 213 G revised 10/2010 3

38 Part III -- COMPREHENSIVE PHYSICAL EXAMINATION REPORT A qualified licensed physician, nurse practitioner, or physician assistant must complete Part III. The exam must be done no longer than one year before entry into kindergarten or elementary school (Ref. Code of Virginia ). Instructions for completing this form can be found at Student s Name: Date of Birth: / / Sex: M F Physical Examination Date of Assessment: / / 1 = Within normal 2 = Abnormal finding 3 = Referred for evaluation or treatment Weight: lbs. Height: ft. in Body Mass Index (BMI): BP HEENT Neurological Skin Age / gender appropriate history completed Lungs Abdomen Genital Anticipatory guidance provided Heart Extremities Urinary TB Risk Assessment: No Risk Positive/Referred Mantoux results: mm EPSDT Screens Required for Head Start include specific results and date: Blood Lead: Hct/Hgb Health Assessment Developmental Screen Assessed for: Assessment Method: Within normal Concern identified: Referred for Evaluation Emotional/Social Problem Solving Language/Communication Fine Motor Skills Gross Motor Skills Hearing Screen Screened at 20dB: Indicate Pass (P) or Refer (R) in each box R L Screened by OAE (Otoacoustic Emissions): Pass Refer Referred to Audiologist/ENT Unable to test needs rescreen Permanent Hearing Loss Previously identified: Left Right Hearing aid or other assistive device Vision Screen With Corrective Lenses (check if yes) Stereopsis Pass Fail Not tested Distance Both R L Test used: 20/ 20/ 20/ Pass Referred to eye doctor Unable to test needs rescreen Dental Screen Problem Identified: Referred for treatment No Problem: Referred for prevention No Referral: Already receiving dental care Recommendations to (Pre) School, Child Care, or Early Intervention Personnel Summary of Findings (check one): Well child; no conditions identified of concern to school program activities Conditions identified that are important to schooling or physical activity (complete sections below and/or explain here): Allergy food: insect: medicine: other: Type of allergic reaction: anaphylaxis local reaction Response required: none epi pen other: Individualized Health Care Plan needed (e.g., asthma, diabetes, seizure disorder, severe allergy, etc) Restricted Activity Specify: Developmental Evaluation Has IEP Further evaluation needed for: Medication. Child takes medicine for specific health condition(s). Medication must be given and/or available at school. Special Diet Specify: Special Needs Specify: Other Comments: Health Care Professional s Certification (Write legibly or stamp): Name : Signature: Date: / / Practice/Clinic Name: Address: Phone: - - Fax: MCH 213 G revised 10/2010 4

39 7-2.3(B)F2 COMMONWEALTH OF VIRGINIA CERTIFICATE OF RELIGIOUS EXEMPTION Name of Student Date of Birth Student I.D. Number The administration of immunizing agents conflicts with the above-named student s/my religious tenets or practices. I understand that, in the occurrence of an outbreak, potential epidemic or epidemic of a vaccinepreventable disease in my/my child s school, the State Health Commissioner may order my/my child s exclusion from school, for my/my child s own protection, until the danger has passed. Signature of parent/guardian/student Date AFFIRMATION In the County/City of, State of ; to wit: This day of, personally appeared before me, a notary public in and for the County/City and State aforesaid,, who did certify that there are no willful misrepresentations in, or falsifications of, the above statements. Notary Public My commission expires: