Additional Required Documentation

Transcription

1 Washington Virtual Academies Enrollment Processing Center 1584 McNeil Street, Suite 200 DuPont, WA Ph Fx Additional Required Documentation Part 1: (The pages supplied in this packet) o Release of Student Records If the student is a home-schooled student, the parent should write Always Home-schooled on the form. o OSPI Statement of Understanding o HS WAVA Special Programs Form o HS Course Enrollment Form ***If applying to enroll in WAVA program affilated with the Omak School District, write in Omak School District in the write in area, otherwise write in Monroe School District.*** o Request for Release CHOICE ***If applying to enroll in WAVA program affilated with the Omak School District, write in Omak School District in the write in area, otherwise write in Monroe School District.*** o WAVA-HS District Release ***If applying to enroll in WAVA program affilated with the Omak School District, write in Omak School District in the write in area, otherwise write in Monroe School District.*** o Intra-Local Attendance Agreement (Must complete if student is sharing attendance with WAVA and the local school district, if applicable make sure to select the correct form.) o Declaration of Intent to Provide Home-Based Instruction (This form is not necessary if the student is attending WAVA full-time) o WAVA Immunization Forms (complete the form applicable to your child) Part 2: (Items you will need to supply) Before you send in your enrollment packet, please be sure you have completed and included copies (do not include originals) of the following: o Proof of age for each student applying to our program (copy of Birth Certificate) o Current proof of residency (Copy of utility bill in the form of: water, sewer, gas, garbage, electric, or propane, lease,or rental agreement) o A copy of official transcripts (9-12) o A copy of your student s Multifactored Evaluation/504 or IEP, if applicable o District Release Form (This form must be picked up at your local school district office) Fax or mail the required documents listed in both parts 1 and 2 to WAVA-HS. The fax number for WAVA-HS is If you are unable to fax, please mail the documents to: Washington Virtual Academies 1584 McNeil Street Suite 200 DuPont, WA 98327

2 Washington Virtual Academies Enrollment Processing Center 1584 McNeil Street, Suite 200 DuPont, WA Ph Fx Release of Student Records 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: ( ) Prior School Information Name of Prior School: School s Address: street city county state zip School s Phone: ( ) School s Fax: ( ) Name of Parent or Legal Guardian: first last Parent/Guardian s Signature: Date: SCHOOL OFFICIALS ONLY: Send student records to: Washington Virtual Academies 1584 McNeil Street, Suite 200 DuPont, WA 98327

3 1584 McNeil Street, Suite 200 DuPont, WA ph. (253) fx. (253) OSPI STATEMENT OF UNDERSTANDING In accordance with the Alternative Learning Experience Implementation Standards, reference WAC (3)(e), prior to enrollment parent(s) or guardian shall be provided with, and sign, documentation attesting to the understanding of the difference between home-based instruction and enrollment in an alternative learning experience (ALE). Provided on this form are descriptions of the difference between home-based instruction and an ALE. Please read these descriptions and sign below. Summary Description Home-Based Instruction Is provided by the parent or guardian as authorized under RCW 28A.200 and 28A Students are not enrolled in public education. Students are not subject to the rules and regulations governing public schools, including course, graduation, and assessment requirements. The public school is under no obligation to provide instruction or instructional materials, or otherwise supervise the student s education. Alternative Learning Experience Washington Virtual Academy (WAVA) Is authorized under WAC Students are enrolled in public education either full-time or part-time. Students are subject to the rules and regulations governing public school students including course, graduation, and assessment requirements for all portions of the ALE. Learning experiences are: Supervised, monitored, assessed, and evaluated by certificated staff. Provided via a written student learning plan. Provided in whole, or part outside the regular classroom. Part-time Enrollment of Home-Based Instruction Students Home-based instruction students may enroll in public school programs, including ALE programs, on a part-time basis and retain their home-based instruction status. In the case of part-time enrollment in ALE, the student will need to comply with the requirements of the ALE written student learning plan, but not be required to participate in state assessments or meet state graduation requirements. I have read the descriptions of home-based instruction and alternative learning experience provided and I understand the difference between home-based instruction and the alternative learning experience program in which my child is enrolling. Parent Signature Date Name(s) of Student(s) School Year

4 Washington Virtual Academies a program of Steilacoom Historical School District No. 1 Special Programs To help us better serve your student s needs and transition, we would like to know about any special services your student has received or is required to receive under state or federal law. This information will not be used to determine enrollment eligibility, but will be used to ensure that your child is provided with proper services. 1. Has your student EVER participated in any of the following special services? (Circle your response) Yes or No If yes to above Gifted & Talented ESL (English as a Second Language) Title 1/Chapter 1 question, check applicable service(s) 504 Plan Special Education/IEP 2. Does your student have an IEP? Yes No 3. What is the primary language used in the home regardless of the language spoken by the student? 4. Is a language other than English spoken at home? Yes No If so, what language? 5. Does your child speak a language other than English? Yes No If so, what language? Custody Information 6. Is there a joint custody plan in effect? Yes No If yes, a copy of the plan must be on file with the school for enforcement. 7. Is there a restraining order? Yes No If yes, a copy of the plan must be on file with the school for enforcement. Restraining order is against: Mother Father Other: Please submit a copy of custody plan and/or restraining order as they pertain to your student. Certification and Signature Certification and Signature I certify that all of the above information is true and correct. Signature: Date: Student Name:

5 Washington Virtual Academies 09/10 HS Course Enrollment Form This letter is to provide notice that the parent is exercising the option to have his or her child attend another school district under Washington inter-district choice (RCW 28A ). The following student will attend classes in the (write in) and participate in courses offered through the Washington Virtual Academies (WAVA) for the 2009/10 school year: Student Information: Student Name: Grade 2009/10: Date of Birth: Parent/Guardian Name: Address/City: Zip Code: Home Telephone: Work Telephone: Enrollment Calculation: Please follow these instructions: 1. Complete one form per student 2. List the courses to be taken at WAVA. 3. Add the total numbers of Credits and FTE to be taken 4. Fax signed copy to WAVA office at (253) Course Titles Credits FTE Course Titles Credits FTE 1 st Semester Titles 1 st Sem 1 st Sem 2 nd Semester Titles 2 nd Sem 2 nd Sem Totals Totals Home School Status (separate from WAVA) Are you establishing Home School Status? Yes No If yes, have you turned in a Letter of Intent to Home School to WAVA? Yes No ***WAVA is a public school program, for a complete definition refer to the OSPI Statement of Understanding*** Parent Name Parent Signature Date 1584 McNeil St. Suite 200 Phone (253) DuPont, WA Fax (253)

6 09/10 WAVA HS Course Catalog, Grades 9-12 English/ Language Arts Math Science Level 2 Core Level 3 Comprehensive Level 4 Honors and AP ENG102: Literary ENG103: Literary ENG304: Honors Analysis and Analysis and Composition American Literature Composition I I ENG500: AP English ENG202: Literary ENG203: Literary Language and Analysis and Analysis and Composition Composition Composition II II ENG510: AP English ENG302: American ENG303: American Literature and Literature Literature Composition ENG402: British and ENG403: British and World Literature World Literature MTH102: Math Foundations MTH112: Pre-Algebra MTH122: Algebra I MTH302: Algebra II MTH312: Business and Consumer Math SCI102: Physical Science SCI112: Earth Science SCI202: Biology SCI302: Chemistry MTH113: Pre-Algebra MTH123: Algebra I MTH203: Geometry MTH303: Algebra II MTH403: Pre-Calculus and Trigonometry SCI113: Earth Science SCI203: Biology SCI303: Chemistry SCI403: Physics MTH124: Honors Algebra I MTH304: Honors Algebra II MTH500: AP Calculus AB MTH510: AP Statistics SCI304: Honors Chemistry SCI510: AP Chemistry SCI520: AP Physics B History/ Social Sciences HST102: World History HST212: Geography and World Cultures (1 sem) HST302: U.S. History HST402: U.S. Government and Politics (1 sem) HST412: U.S. and Global Economics (1 sem) HST103: World History HST203: Modern World Studies HST213: Geography and World Cultures (1 sem) HST303: U.S. History HST403: U.S. Government and Politics (1 sem) HST413: U.S. and Global Economics (1 sem) HST304: Honors U.S. History HST500: AP U.S. History HST510: AP U.S. Government and Politics (1 sem) HST520: AP Macroeconomics (1 sem) HST530: AP Microeconomics (1 sem) HST540: AP Psychology (1 sem) 1584 McNeil St. Suite 200 Phone (253) DuPont, WA Fax (253)

7 09/10 WAVA HS Course Catalog, Grades 9-12 (continued) World Languages Electives/ Other WLG100: Spanish I WLG200: Spanish II WLG300: Spanish III WLG110: French I WLG210: French II WLG310: French III WLG120: German I WLG220: German II WLG130: Latin I WLG230: Latin II WLG140: Chinese I WLG240: Chinese II OTH010: Skills for Health (1 sem) OTH020: Physical Education (1 sem or more) OTH030: Career Planning (1 sem) ART010: Fine Art ART020: Music Appreciation BUS010: Business Communication and Career Exploration (1 sem) BUS020: Business and Personal Relationships (1 sem) BUS030: Personal Finance (1 sem) HST010: Anthropology (1 sem) TCH010: Computer Literacy I (1 sem) TCH020: Computer Literacy II (1 sem) avail. Winter 2009 TCH030: Digital Photography and Graphics (1 sem) TCH040: Web Design (1 sem) TCH050: Digital Video Production (1 sem) TCH060: C++ Programming (1 sem) TCH070: Game Design I (1 sem) TCH080: Game Design II (1 sem) TCH090: 3D Game Creation (1 sem) TCH016: Flash Animation (1 sem) WLG500: AP Spanish Language WLG510: AP French Language 1584 McNeil St. Suite 200 Phone (253) DuPont, WA Fax (253)

8 Resident School District 2009/2010 Request for Release CHOICE One form per student Note: If the FTE of the student will be shared between districts, the CHOICE law does not apply. The sharing of FTE requires an Interdistrict Agreement. New Request Annual Renewal Student Name: Grade 2009/10: Date of Birth: Parent/Guardian Name: Address/City: Zip Code: Home Telephone: Work Telephone: Resident, (Sample) School District: Currently Enrolled? Y N School District Requested: School/Program Requested: WAVA Please check all that apply: Special Ed 504 Discipline Issues Regular Ed BASIS FOR REQUEST OF RELEASE A financial, educational, safety, or health condition affecting the student would be reasonably improved as a result of the transfer. Attendance at the school requested is more accessible to the parent s place of work or childcare. There is some other special hardship or detrimental condition affecting the student or the student s immediate family that would be alleviated as a result of the transfer. PLEASE EXPLAIN. USE BACK OF PAGE, IF NECESSARY: DURATION OF RELEASE: (Optional) THE FOLLOWING CONDITIONS MAY CAUSE THE RELEASE TO BE TERMINATED, AS AUTHORIZED IN SCHOOL DISTRICT BOARD POLICY. (SPECIFY CONDITIONS HERE) Parent/Guardian Signature: Date: CHOICE AGREEMENT Legal Reference: RCW28A through 230; WAC Under the CHOICE law, the receiving school district effectively becomes the resident school district for all matters related to the education of the student (special education, academic accountability, Core Student Record System, etc). CERTIFICATION OF RELEASE FROM: Approved Denied (Name of school district) Student Name: Releasing School District Authorized Signature: Title: CERTIFICATION OF NON-RESIDENT SCHOOL ACCEPTANCE FROM: Approved Denied (Name of school district) Non-Resident, accepting School District Authorized Signature: 1584 McNeil St. Suite 200 Phone (253) DuPont, WA Fax (253)

9 Request for Release New Request Annual Renewal Student Name: Grade 2009/10: Date of Birth: Parent/Guardian Name: Address: City: Zip Code: Home Telephone: Work Telephone: Resident School District: Currently Enrolled? Y N School District Requested: (write in) School/Program Requested: WAVA Please check all that apply: Special Ed 504 Discipline Issues Regular Ed BASIS FOR REQUEST OF RELEASE A financial, educational, safety or health condition affecting the student would be reasonably improved as a result of the transfer. Attendance at the school requested is more accessible to the parent s place of work or childcare. There is some other special hardship or detrimental condition affecting the student or the student s immediate family that would be alleviated as a result of the transfer. PLEASE EXPLAIN. USE BACK OF PAGE, IF NECESSARY DURATION OF RELEASE: Parent/Guardian Signature: Date: CERTIFICATION OF RELEASE FROM (Name of school district) Approved Denied Student Name Releasing School District Authorized Signature Date Title CERTIFICATION OF NON-RESIDENT SCHOOL ACCEPTANCE FROM Approved Denied Date: Washington Virtual Academies Authorized Signature: Title:

10 09/10 HS Intra-local Attendance Agreement Resident School District The below named student is enrolled in your district and would like to exercise his/her option to take some courses through WAVA-HS (RCW 28A ). According to WAC , school districts have authority to enter into interdistrict cooperative agreements for instructional services with other school districts under RCW 28A Please complete the form below to ensure our districts are reporting the correct FTE. Student Information: Student Name: Parent/Guardian Name: Address/City: Grade 2009/10: Date of Birth: City: Zip Code: Home Telephone: Work Telephone: Enrollment Calculation: Please follow these instructions: 1. Parent & Resident District Official must complete one form per student 2. List the courses to be taken at WAVA and at your local school. 3. Add the total numbers of Credits and FTE to be taken - - FTE cannot exceed Have resident school fill out Resident District Courses. 5. Fax signed copy to WAVA office at (253) and provide a copy to your resident district WAVA Course Titles Credit FTE Resident School Course Titles Credit FTE Totals Totals Total Cumulative Credits and FTE Between WAVA and Resident District Credits FTE FTE ATTENDANCE AGREEMENT * Final acceptance into WAVA pending pending approval of (write in) Parent Name Parent Signature Date * Final acceptance into WAVA pending pending approval of (write in) Name of Resident School District: Address: City: Zip Code: Phone:: Name of District Official Title of District Official Signature of District Official Date WAVA Official Signature of WAVA Official Title of WAVA Official Date 1584 McNeil St. Suite 200 Phone (253) DuPont, WA Fax (253)

11 1584 McNeil St. Suite 200 Phone (253) DuPont, WA Fax (253)

12 Reviewed by: Date: Staff Signature Is there an accompanying signed Certificate of Exemption on file? Yes No Certificate of Immunization Status (CIS) Child s Last Name: First Name: Middle Initial: Child s Address: DOH Rev: 10/15/08 Child s Birthdate: Child s Sex: Parent/Guardian Name: Parent/Guardian Day Phone: If completing by hand, write the vaccine in the row to the left of Dose and the date the vaccine was received in the Date column. Age column is optional. Required for School and Child Care/Preschool Required for Child Care/Preschool Only Vaccine Dose Date Age Vaccine Dose Date Age Vaccine Dose Date Age Hepatitis B (Hep B) Pneumococcal (PCV, PPV) Hepatitis A (Hep A) Meningococcal (MCV4, MPSV4) Hepatitis B (Hep B) Alternate schedule for teens 1 1 Polio (IPV, OPV) 2 1 Human Papillomavirus (HPV) Rotavirus Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT) Influenza (most recent) Other Measles, Mumps, Rubella (MMR) Diphtheria, Tetanus, Pertussis (Tdap, Td) 1 2 Varicella (chickenpox) Haemophilus influenzae type b (Hib) Verification of varicella disease history 3 4 See the back of this page for documentation of immunity, a vaccine trade name reference guide, and a vaccine abbreviation list. Health Care Provider (HCP) Verified HCP Verified by Registry Parental Report Signed note from HCP attached or HCP provider signature here: No HCP Sig required if box at left checked. If school staff find verification in the Registry, then school staff must: ONLY acceptable for some grades. Write date or age child had disease: I certify that the information provided here is correct and verifiable. Signature of Parent or Guardian Date Licensed HCP Signature (MD, DO, ND, PA, ARNP) Date Either initial with parent approval or get parent signature below: Staff initials indicating parent approval: Parent Signature indicating approval:

13 Documentation of Immunity by Blood Test (titer) I certify that the child named on this form has laboratory evidence of immunity to (check all that apply): Diphtheria Hepatitis A Hepatitis B Hib Measles Mumps Polio Rubella Tetanus Varicella Other (list): lab report(s) attached (required) X Typed or Printed Name of Licensed Health Care Provider (MD, DO, ND, PA, ARNP) X Signature of Licensed Health Care Provider (required) Date (required) Vaccine Trade Names* Read down and across - Trade Names are in Alphabetical Order. Vaccine Abbreviations* Read down Abbreviations are in Alphabetical Order. Trade Name Vaccine Trade Name Vaccine Abbreviations Full Vaccine Name Acel-Imune DTaP Menomune MPSV4 DT Diphtheria, Tetanus ActHIB Hib OmniHIB Hib DTaP Diphtheria, Tetanus, acellular Pertussis Adacel Tdap Pediarix DTaP + IPV + Hep B DTP Diphtheria, Tetanus, Pertussis Boostrix Tdap PedvaxHIB Hib Flu (TIV or LAIV) Influenza Certiva HPV Pentacel DTaP + IPV + Hib HBIG Hepatitis B Immune Globulin Comvax Hib + Hep B Pentavalente DTaP + Hep B + Hib Hep A (HAV) Hepatitis A Daptacel DTaP Pneumovax PPV23 Hep B (HBV) Hepatitis B Decavac Td Prevnar PCV or PCV7 Hib Haemophilus influenzae type b Engerix-B Hep B ProHIBiT Hib HPV Human Papillomavirus Fluarix Flu ProQuad MMRV IPV Inactivated Poliovirus Vaccine FluMist Flu Quadracel DTaP + IPV MCV4 Meningococcal Conjugate Vaccine Fluvirin Flu Recombivax Heb B MPSV4 Meningococcal Polysaccharide Vaccine Fluzone Flu Rotarix Rotavirus MMR Measles, Mumps, Rubella Gardasil HPV RotaTeq Rotavirus MMRV Measles, Mumps, Rubella, Varicella Havrix Hep A Tetramune DTP + Hib OPV Oral Poliovirus vaccine HibTITER Hib TriHIBit DTaP + Hib PCV or PCV7 Pneumococcal Conjugate Vaccine HyperTET TIG Tri-Immunol DTP PPV23 Pneumococcal Polysaccharide Vaccine HyperHEP B HBIG Tripedia DTaP Rota (RV1 or RV5) Rotavirus Ipol IPV Twinrix Hep B + Hep A Td Tetanus, Diphtheria Infanrix DTaP Vaqta Hep A Tdap Tetanus, Diphtheria, acellular Pertussis Kinrix DTaP + IPV Varivax Varicella TIG Tetanus immune globulin Menactra MCV4 VAR or VZV Varicella *These lists may not be comprehensive; visit for updated lists. DOH Revised: 10/15/08

14 Certificate of Exemption (COE) From School, Child Care and Preschool Immunization Requirements 1 DOH Revised: 10/15/08 Child s Last Name: First Name: Middle Initial: Child s Address: Child s Birthdate: Child s Sex: Parent/Guardian Name: Parent/Guardian Day Phone: Please choose the exemption(s) that apply to your child as listed below. Temporary Medical Exemption Personal/Philosophical Exemption Permanent Medical Exemption I certify that the child named on this form is medically exempted from the requirement for the following vaccine(s): Until Vaccine(s) Date (or Perm.) Religious Exemption I do not want my child to get the following vaccine(s). Diphtheria Hepatitis B Hib Measles Mumps Pertussis (whooping cough) Pneumococcal Polio Rubella Tetanus Varicella (chickenpox) Other (indicate): X Type or Print Name of Licensed Health Care Provider (MD, DO, ND, PA, ARNP) X Signature of Licensed Health Care Provider Date Parent/Guardian Notice: I certify that the information provided here is correct and verifiable. I understand that if there is an outbreak of a vaccinepreventable disease my child has not been fully immunized against (as indicated above, for medical, personal/philosophical or religious reasons), my child may be at risk for disease and can be excluded from school, child care or preschool until the outbreak is over. Signature of Parent/Guardian Date 1 RCW 28A state that before or on the first day of every child s attendance at any public and private school or licensed day care center in Washington State must present proof of either: (1) full immunization, (2) the initiation of and compliance with a schedule of immunization, as required by rules of the state board of health, or (3) a certificate of exemption, signed by a parent or guardian. Medical exemptions must be signed by a licensed health care provider.