Enrollment Forms Packet (EFP)

Transcription

1 Enrollment Forms Packet (EFP) Oklahoma Virtual Charter Academy Enrollment Processing Center 2300 Corporate Park Drive Suite 200 Herndon, VA Ph Fx Please review the information below. Based on your student(s) grade and applicable circumstances, you are required to submit documentation in order to complete this step in the enrollment process. You can fax, scan and , or mail the required paperwork. Important Note: Please send copies, do not mail the original documents Fax (preferred): Scan and Mail: Oklahoma Virtual Charter Academy Enrollment Processing Center 2300 Corporate Park Drive Suite 200 Herndon, VA Required For? Item Description Provided by? Oklahoma Transfer Application Please use the instruction provided to complete this form. All Open Transfer Applications must be submitted by June 2 nd Authorization for Use of Electronic Signatures In order to accept all digitally signed documents, you must submit this form. Home Language Survey Title VII Student Eligibility Certification 506 form Please complete and sign this form. This form must be signed and submitted. If it does not apply to your student, only include your student s name and your signature and write N/A on the form. If it is applicable to your student, please complete all sections of the form. Provided in this packet Enrollment Question- naire/mckinney- Vento Act Please complete and sign this form. Required for all Students Release of Records By filling out this form, you are giving our school permission to request your student s official records from their previous school after the approval process. If your child was Homeschooled please indicate it on the form, fill out the top portion and sign it. Attend an In-Person Orientation Session It is required for you and your student to attend an In-person Start-Up Success session that provides an introduction to the online learning setting. Parents will attend a policy session to learn about important expectations for success in an online school while students take a reading assessment (Kindergarten-6th grade) and/or math assessment (grades 3-12). As part of the parent session, parents will set an appointment to develop a customized Individualized Learning Plan (ILP) for each student. Report card/transcripts must be submitted before the ILP conference can be conducted. These sessions will start in February. Provided during Orientation Session Proof of Age Official Birth Certificate (not the hospital issued certificate) Proof of Residency Current Utility bill (dated within the past 6 months) OR Tax statement OR Mortgage/Rental Agreement statement showing physical address, not post office box OR Voter Registration. Proof of Internet Complete Internet Bill. Immunization Record Current Immunization Record. Required for all Kindergarten, 1 st and 3 rd Grade Students Proof of Vision Screening This form is required within 30 days of your student s approval date. Required for all Kindergartent -9 th Grade Students Report Card The most recent Report Card. Provided by you Required for all 10 th - 12 th Grade Students Transcripts You will need to request a copy of your student s transcript from your student s current school, which will allow your student s academic standing. This is required in order to place all 10 th -12 th graders. Required for all Students that have an IEP or other Special Education needs IEP Evaluation Team Report A copy of your student s current IEP (Individualized Education Plan). Because the IEP expires yearly, please submit the current IEP. The Evaluation Team Report is valid for 3 years. If you do not have a copy of your student s ETR, please obtain a copy from your student s current school. Required for all Students that have a 504 plan 504 Accommodation Plan A copy of your student s current 504 Accommodation Plan. Because the 504 expires yearly, please submit the current 504.

2 An Open Transfer Application must be completed for each student. (You may use one form for up to two students.) Fax to OR mail to: Oklahoma Virtual Charter Academy Enrollment Processing 2300 Corporate Drive, Herndon, VA Applications must be received by noon (CST), 06/02/14. OKLAHOMA VIRTUAL ACADEMY Revised December 1, 2013 A Receiving District (transfer to) : Enter Oklahoma as the County Name, enter Choctaw- Nicoma Park as the District Name, and enter Oklahoma Virtual Charter Academy as the Site Requested. A D G H Parent s Application for an Open Transfer Beginning School Year Instructions: No later than the first Monday in June 2014, the parent/guardian must submit this application to the Receiving District to apply for the school year. No later than 30 days after receiving an Open Transfer application, the Receiving District must notify the parent/guardian and the Sending District of their decision to approve or deny. Within 10 days of receiving approval notification from the Receiving District, the parent shall notify the Receiving District that they intend to enroll their student in the fall. The Receiving District must complete data entry of Open Transfer applications no later than the first Monday in June which will notify the Sending District by the deadline. [70 O.S , 8-10] [House Bill 2131 effective November 2013] RECEIVING DISTRICT (transfer to) County Name District Name School Site Requested Oklahoma Virtual Charter Academy SENDING/RESIDENT DISTRICT (transfer from) County Name District Name School Site Check here if child is currently Home Schooled. STUDENT INFORMATION E First Name Middle Name Last Name Birth Date Grade Level IEP* Date for (Yes / No) I.E.P. Meeting *An IEP is an Individualized Education Program. If parent answered yes that child is currently on an IEP, a representative from both districts must be present for an IEP meeting held to discuss the student s IEP needs. Applicable IEP records must be submitted from the student s school to the Receiving District and shall be maintained by both districts in accordance with federal and state laws. An IEP Service Agreement does not constitute a transfer under the Education Open Transfer Act and should not be formalized or processed by use of this form. PARENT/LEGAL GUARDIAN MUST COMPLETE AND SIGN: First and Last Name Oklahoma Choctaw-Nicoma Park (optional) Street Address City Zip Code Home Phone (Area Code) Alternate Phone (Area Code) 1. Does the parent/legal guardian have another child currently attending this same Receiving District on a previous Open Transfer? Yes / No If Yes enter Sibling Name(s): 2. Is this parent/legal guardian a TEACHER employed by this Receiving District? Yes / No 3. Is this parent/legal guardian requesting a district that provides a SPECIALIZED DEAF EDUCATION program? Yes / No 4. Is this parent/legal guardian requesting to CANCEL an approved Open Transfer for the student(s) listed? Yes / No B C SAMPLE F B C D E F G H Sending/Resident District (transfer from) : Enter your county of residence as the County Name, enter your district of residence as the District Name, and enter the school your student would attend as the School Site. If you are currently homeschooling your student, check this box. Otherwise, disregard this section. Student Information: Complete First Name, Middle Name, Last Name, Birth Date, and Grade level(s) that all students will be entering in the Fall (up to two students). IEP*: Enter Yes for applicable student(s) with an IEP; enter No if student(s) do not have an IEP. Note: An IEP and all necessary records must be submitted to the receiving District if this transfer is for any student with a disability being served through an IEP. Such records shall be maintained by both districts in accordance with federal and state laws. Date for I.E.P. Meeting: A joint district meeting for student(s) with an IEP must be held prior to approval of a transfer and the Date for I.E.P. Meeting section will be used by OVCA for scheduling purposes. You do not need to enter information in this section. Parent or Legal Guardian Information : Enter your First Name, Last Name, (optional, but preferred), Street Address, City, Zip, Home Phone, and Alternate Phone numbers with area codes. Check Yes or No for the following questions: 1. Does the parent/legal guardian have another child currently attending the Receiving District (Choctaw-Nicoma Park) on a previous Open Transfer? (Enter the sibling(s) name(s) if yes.) I An Open Transfer may occur outside of statutory time frame with documentation provided when above questions 1, 2 or 3 are Yes. Pursuant to the provisions of the statutes of the state of Oklahoma, and the rules and regulations of the State Board of Education, application is hereby made to permit the child listed on this form to transfer from their resident Sending District to the Receiving District as indicated on this form. The parent/guardian applicant verifies by their signature (below) that he/she is the custodial parent or legal guardian of the child/children listed above and hereby acknowledges that if this transfer application is approved, the parent/guardian shall be bound by the Compulsory School Attendance Laws of Oklahoma rules and all regulations of the Receiving District named on this transfer application. SIGNATURE of Parent/Guardian Date 2. Is the parent/legal guardian requesting this transfer a TEACHER at the Receiving District? 3. Is the parent/legal guardian requesting this transfer specifically to a Receiving District that provides a SPECIALIZED DEAF EDUCATION program? 4. Is the parent/legal guardian requesting to CANCEL an approved Open Transfer for the student(s) listed? Receiving District received this form on, The decision must be within 30 days which is, I Print and sign your name as parent/guardian and date the Open Transfer Application.

3 Revised December 1, 2013 Parent s Application for an Open Transfer Beginning School Year Instructions: No later than the first Monday in June 2014, the parent/guardian must submit this application to the Receiving District to apply for the school year. No later than 30 days after receiving an Open Transfer application, the Receiving District must notify the parent/guardian and the Sending District of their decision to approve or deny. Within 10 days of receiving approval notification from the Receiving District, the parent shall notify the Receiving District that they intend to enroll their student in the fall. The Receiving District must complete data entry of Open Transfer applications no later than the first Monday in June which will notify the Sending District by the deadline. [70 O.S , 8-10] [House Bill 2131 effective November 2013] RECEIVING DISTRICT (transfer to) SENDING/RESIDENT DISTRICT (transfer from) County Name Oklahoma County Name District Name Choctaw/Nicoma Park District Name School Site Requested OVCA School Site Check here if child is currently Home Schooled. STUDENT INFORMATION First Name Middle Name Last Name Birth Date Grade Level IEP* Date for (Yes / No) I.E.P. Meeting *An IEP is an Individualized Education Program. If parent answered yes that child is currently on an IEP, a representative from both districts must be present for an IEP meeting held to discuss the student s IEP needs. Applicable IEP records must be submitted from the student s school to the Receiving District and shall be maintained by both districts in accordance with federal and state laws. An IEP Service Agreement does not constitute a transfer under the Education Open Transfer Act and should not be formalized or processed by use of this form. PARENT/LEGAL GUARDIAN MUST COMPLETE AND SIGN: First and Last Name (optional) Street Address City Zip Code Home Phone (Area Code) Alternate Phone (Area Code) 1. Does the parent/legal guardian have another child currently attending this same Receiving District on a previous Open Transfer? Yes / No If Yes enter Sibling Name(s): 2. Is this parent/legal guardian a TEACHER employed by this Receiving District? Yes / No 3. Is this parent/legal guardian requesting a district that provides a SPECIALIZED DEAF EDUCATION program? Yes / No 4. Is this parent/legal guardian requesting to CANCEL an approved Open Transfer for the student(s) listed? Yes / No An Open Transfer may occur outside of statutory time frame with documentation provided when above questions 1, 2 or 3 are Yes. Pursuant to the provisions of the statutes of the state of Oklahoma, and the rules and regulations of the State Board of Education, application is hereby made to permit the child listed on this form to transfer from their resident Sending District to the Receiving District as indicated on this form. The parent/guardian applicant verifies by their signature (below) that he/she is the custodial parent or legal guardian of the child/children listed above and hereby acknowledges that if this transfer application is approved, the parent/guardian shall be bound by the Compulsory School Attendance Laws of Oklahoma rules and all regulations of the Receiving District named on this transfer application. SIGNATURE of Parent/Guardian Date Receiving District received this form on, The decision must be within 30 days which is, 2014.

4 AUTHORIZATION FOR USE OF ELECTRONIC SIGNATURE An electronic signature is recognized as a valid signature under the Uniform Electronic Transactions Act, 12A O.S et seq. By signing this document, I hereby authorize Oklahoma Virtual Charter Academy, hereinafter school to accept all correspondence transmitted by me via electronic mail from the address submitted herein, as a valid electronic message from me and I agree that until I notify school in writing that my address is changed, all communications sent out from this address shall be upon my digital signature represented by the following: /s/ shall be acceptable as a replacement for my written signature. Parent/Legal Guardian Signature I understand that I am responsible for notifying the school in the event that my changes by mailing an updated signed Authorization for Use of Electronic Signature form to the school. I will not allow another person to utilize my signature and I am aware that school assumes no liability for the event or the consequences of another party gaining access to my account, and electronically impersonating me. I understand that I am not guaranteed confidentiality of information that is transmitted electronically (by or by FAX), by myself, the school or others. In the event that I request, either by electronic signature or in writing, that confidential information be transmitted, I release school from all liability related to the release of the requested information. School will do its utmost to insure confidentiality of all communication between me and the school. By signing below, I release school from any responsibility or liability for consequences pertaining to this request. Student s Name Parent or Legal Guardian s Name Street Address Date of Birth Today s Date Primary Address City State Zip Code Signature By signing this Authorization for Use of Electronic Signature, all other previous submissions of this form received by school is invalid.

5 Janet Barresi State Superintendent of Public Instruction Oklahoma State Department of Education Name of Student: HOME LANGUAGE SURVEY FOR PRE-K-12 SCHOOL DISTRICTS Last Name First Name Middle Name Student ID #: Gender: Male Female School Site: Grade: Date of Birth: Place of Birth (City/State/Country): Is the student of Hispanic or Latino culture or origin? Yes No Select one or more of the following races: African American/Black American Indian/Alaskan Native Asian Native Hawaiian or Other Pacific Islander White Parent s/guardian s Name: Parent s/guardian s Address: Parent s/guardian s Telephone Number: ( ) Cell Phone: 1. Is a language other than English used in your home? Yes No If NO, go to numbers 6 and 7. If YES, what is that language? 2. Is that language spoken in the home MORE OFTEN than English? LESS OFTEN than English? 3. What language is spoken by adults in the home? 4. What was the first (1 st ) language your child learned to speak? 5. What was the date (month and year) your child first enrolled in a school in the United States? 6. Parent/Guardian Signature: 7. Date: FOR SCHOOL USE ONLY THIS FORM MUST BE COMPLETED EVERY YEAR WITH CURRENT TEST DATA FOR STATE ACCREDITATION. If a language other than English is spoken MORE OFTEN (see question #2), the student automatically qualifies as bilingual on application for accreditation. OR If a language is spoken LESS OFTEN, student qualifies as bilingual on application for accreditation if he or she meets ONE OF THE FOLLOWING: 1. Scores 35% or below on norm-referenced test (NRT) on the composite reading score. 2. Scores limited knowledge or unsatisfactory on Reading Oklahoma Core Curriculum Tests (OCCTs). 3. Designated Limited English Proficient on an Oklahoma English language proficiency assessment: WIDA ACCESS for English language learners (ELLs) Test, WIDA Placement Test (including K W-APT, W-APT, and Kindergarten MODEL), or the Oklahoma Pre-K Language Screening Tool. Documentation of a test result for students who marked LESS OFTEN: 1. NRT Test Date: Name of the NRT: Reading Total Composite Score: 2. Reading OCCT Date: Score on Reading OCC T: Limited Knowledge Unsatisfactory Satisfactory Advanced 3. ACCESS for ELLs Test Date: Score on ACCESS for ELLs: 1 2 WIDA Placement Test (K W-APT, W-APT, or Kindergarten MODEL) Date: Score on K W-APT, W-APT, or MODEL: 1 2 Oklahoma Pre-K Language Screening Tool Date: Street City Zip Code Score on Pre-K Language Screening Tool: Note: Have test score documentation available for regional accreditation officer review. 1 Composite Score 2 Literacy Score

6 OMB Number: Expiration Date: 04/30/2013 U.S. DEPARTMENT OF EDUCATION OFFICE OF INDIAN EDUCATION WASHINGTON, DC TITLE VII STUDENT ELIGIBILITY CERTIFICATION Elementary and Secondary Education Act, Title VII, Part A, Subpart 1 Parents: Please return this completed form to your child's school. In order to apply for a formula grant under the Indian Education Program, your child's school must determine the number of Indian children enrolled. Any child who meets the following definition may be counted for this purpose. You are not required to complete or submit this form to the school. However, if you choose not to submit a form, the school cannot count your child for funding under the program. This form will become part of your child's school record and will not need to be completed every year. This form will be maintained at the school and information on the form will not be released without your written approval. Definition: Indian means any individual who is (1) a member (as defined by the Indian tribe or band) of an Indian tribe or band, including those Indian tribe or bands terminated since 1940, and those recognized by the State in which the tribe or band reside; or (2) a descendent in the first or second degree (parent or grandparent) as described in (1); or (3) considered by the Secretary of the Interior to be an Indian for any purpose; or (4) an Eskimo or Aleut or other Alaska Native; or (5) a member of an organized Indian group that received a grant under the Indian Education Act of 1988 as it was in effect October 19, NAME OF CHILD (As shown on school enrollment records) School Name Date of Birth Grade NAME OF TRIBE, BAND OR GROUP Tribe, Band or Group is: (check one) Organized Indian Group Federally Recognized, State Meeting #5 of the Including Alaska Native Recognized Terminated Definition Above Name of individual with tribal membership: Individual named is (check one): Child Child's Parent Child's Grandparent Proof of membership, as defined by tribe, band, or group is: A. Membership or enrollment number (if readily available) OR Other (explain) Name and address of organization maintaining membership data for the tribe, band or group: I verify that the information provided above is accurate: PARENT'S SIGNATURE DATE Mailing Address Telephone Notice: Public Reporting Burden Notice on Reverse Side

7 PAPERWORK BURDEN STATEMENT According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is The time required to complete this portion of the information collection per type of respondent is estimated to average: 15 minutes per Indian student certification (ED 506) form; including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C If you have comments or concerns regarding the status of your individual submission of this form, write directly to: Office of Indian Education, U.S. Department of Education, 400 Maryland Avenue, S.W., LBJ/Room 3E200, Washington, D.C

8 Oklahoma Virtual Charter Academy Enrollment Processing Center 2300 Corporate Park Drive Suite 200 Herndon, VA Release of Student Records Ph Fx Please accept this document as formal approval for the release of all official school records (including the record of transcripts, testing information, special education, health and immunization records). Student Information Student s Full Name: first middle last Student s Date of Birth: Student s Legal Address: street apt # city county state zip Home Phone: Homeschooled or Never Previously Enrolled in School (Fill out only if applicable) Check below if applicable: o Student was always previously homeschooled o Student is enrolling in Kindergarten Prior School Information Name of Prior School: School s Address: street city county state zip School s Phone: School s Fax: Sign and Date below Name of Parent or Legal Guardian: first last Parent/Guardian s Signature: Date: SCHOOL OFFICIALS ONLY: Send student records to: Oklahoma Virtual Charter Academy Administration Office P.O. Box 4490 Nicoma Park, OK Fax: Phone: Student s Name: Student s Home Phone: 10

9 OV A This form is intended to address the McKinney-Vento Act. Your answers will help determine residency necessary for enrollment and ensure that certain needs will be met for this student. Presently, where is the student living? Check one box and complete the remainder of the form. Section A In a shelter Temporary with more than one family due to loss of job, loss of housing etc. In a motel, car, or campsite In a temporary with more than one family due to loss of job, loss of housing etc. Alone without parental support (independent living student) Section B Choices in Section A do NOT apply. Student Name: Date of Birth: School: OV A Grade: Male Female Present Address: City: State: Zip: Phone: Last school attended: City: State: Parent/Guardian Name: Parent/Guardian Signature: Date: For School Use Only Student ID #:

10 Date Received: APPLICATION FOR FREE AND REDUCED-PRICE SCHOOL MEALS PART 1. ALL HOUSEHOLD MEMBERS Names of ALL Household Members (First, Middle Initial, Last) Name of School for Each Child/Or Indicate NA If Person Is Not in School Grade Birth Date Check If a Foster Child (Legal Responsibility of Welfare Agency or Court)* *If all children in the household are foster children, skip to Part 5 to sign this form. Check if NO Income (Must be checked if no income) PART 2. BENEFITS IF ANY MEMBER OF YOUR HOUSEHOLD RECEIVES SNAP, TANF, OR FDPIR, PROVIDE THE NAME AND CASE NUMBER FOR THE ONE PERSON WHO RECEIVES BENEFITS AND SKIP TO PART 5. IF NO ONE RECEIVES THESE BENEFITS, SKIP TO PART 3. NAME: CASE NUMBER: PART 3. IF ANY CHILD YOU ARE APPLYING FOR IS HOMELESS, MIGRANT, OR A RUNAWAY, CHECK THE APPROPRIATE BOX AND CALL (YOUR SCHOOL, HOMELESS LIAISON, OR MIGRANT COORDI- NATOR) AT PHONE NUMBER. Homeless Migrant Runaway NOTE TO SFA: A household completing this part does not automatically qualify the child for eligibility. The child must be on the Homeless, Migrant, Runaway List to qualify for free meal benefits. PART 4. TOTAL HOUSEHOLD GROSS INCOME. You must tell us how much and how often. 1. NAME (List only household members with income) 2. GROSS INCOME AND HOW OFTEN IT WAS RECEIVED Earnings From Work Before Deductions Welfare, Child Support, Alimony Pensions, Retirement, Social Security, SSI, VA Benefits All Other Income (Example) Jane Smith weekly every other week monthly monthly Oklahoma State Department of Education Eligibility Documentation Section, July 2013 E-63

11 PART 5. SIGNATURE AND LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER (ADULT MUST SIGN) An adult household member must sign the application. If Part 4 is completed, the adult signing the form also must list the last four digits of his or her social security number or mark the I do not have a social security number box. (See Privacy Act Statement on the back of the next page.) I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get federal funds based on the information that I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my children may lose meal benefits and I may be prosecuted. Sign Here: Date: Print Name: Address: Phone Number: City: State: Zip Code: Last four digits of social security number: *** - **- I do not have a social security number. Part 6: Children s Ethnic and Racial Identities (Optional) Choose one ethnicity: Hispanic or Latino Choose one or more (regardless of ethnicity): Asian American Indian or Alaska Native Black or African American Not Hispanic or Latino White Native Hawaiian or other Pacific Islander 185% of Poverty Level FEDERAL ELIGIBILITY INCOME CHART for School Year 2014 Your children may qualify for free or reduced-price meals if your household income falls at or below the limits of this chart. Household Size For each add l family member, add Annual 21,257 28,694 36,131 43,568 51,005 58,442 65,879 73,316 7,437 Monthly 1,772 2,392 3,011 3,631 4,251 4,871 5,490 6, Twice Per Month Every Two Weeks 886 1,196 1,506 1,816 2,126 2,436 2,745 3, ,104 1,390 1,676 1,962 2,248 2,534 2, Weekly ,124 1,267 1, E-64 Oklahoma State Department of Education Eligibility Documentation Section, July 2013

12 DO NOT FILL OUT THIS PART. THIS IS FOR SCHOOL USE ONLY. Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice a Month x 24, Monthly x 12 Income Eligibility: Total Income: Per: Week Every 2 Weeks Twice a Month Month Year Household Size: Eligibility: Free Reduced Denied Other Categorical Source Eligibility: Categorical Eligibility: SNAP/TANF FDPIR Other Source Categorical Eligibility: Head Start Even Start Homeless Migrant Runaway Head Start Even Start Homeless Migrant Runaway Foster Child Reason: Date Withdrawn: Determining Official s Signature: Date: Confirming Official s Signature: Date: (For Confirmation Reviews Under Verification) Verifying Official s Signature: Date: (If stamped signature is used, signature must be registered with the Secretary of State and the SFA must have this on file.) Privacy Act Statement: This explains how we will use the information you give us. The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced-price meals. You must include the last four digits of the social security number of the adult household member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced-price meals and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules. The United States Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by USDA. (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at < or at any USDA office, or call to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to USDA by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, DC , by fax , or at <program.intake@usda.gov>. Individuals who are deaf, hard of hearing, or have speech disabilities may contact USDA through the Federal Relay Service at or (Spanish). USDA is an equal opportunity provider and employer. Oklahoma State Department of Education Eligibility Documentation Section, July 2013 E-65

13 SHARING INFORMATION WITH MEDICAID/SOONERCARE Dear Parent/Guardian: If your children get free or reduced-price meals, they MAY also be able to get free or low-cost health insurance through Medicaid or SoonerCare. Children with health insurance are more likely to get regular health care and are less likely to miss school because of sickness. Because health insurance is so important to children s well-being, the law allows us to tell Medicaid and SoonerCare that your children are eligible for free and reduced-price meals unless you tell us not to. Medicaid and SoonerCare only use the information to identify children who may be eligible for their programs. Program officials may contact you to offer to enroll your children. Filling out the Application for Free and Reduced-Price Meals does not automatically enroll your children in health insurance. If you do not want us to share your information with Medicaid or SoonerCare, fill out the form below and send in. (Sending in this form will not change whether your children get free or reduced-price meals.) No! I DO NOT want information from my Application for Free and Reduced-Price Meals shared with Medicaid or SoonerCare. If you checked No, fill out the form below to ensure that your information is NOT shared for the child(ren) listed below: Child s Name: Child s Name: Child s Name: Child s Name: School: School: School: School: Signature of Parent/Guardian: Date: Printed Name: Address: For more information, you may call your child s school. E-66 Oklahoma State Department of Education Eligibility Documentation Section, July 2013