JRCS ENROLLMENT CHECKLIST: Tier 1 & 2-4 offered seats

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1 Enrollment Dear Prospective JRCS Parent/Guardian: John Rex Charter Elementary School (JRCS) is a tuition- free public charter school that opened in August, Our mission is to offer quality educational opportunities to children in the heart of downtown Oklahoma City through an innovative public- private partnership. John Rex Charter Elementary School has a four- tiered priority system for enrollment: 1) 2) 3) 4) First, any child residing within the attendance boundaries for JRCS. Residency verification is required at time of application and annually thereafter*; Second, a child who resides outside the JRCS attendance boundaries but within the boundaries of OKC Public Schools. Residency verification is required at time of application and annually thereafter*; Third, a child who resides outside the boundaries of OKC Public Schools and whose parent, guardian, or other person with legal custody is employed within the JRCS attendance boundaries. Employment verification letters must be provided at time of application and annually thereafter*. An out- of- district transfer is required upon admission; Fourth, a child who resides outside the boundaries of OKC Public Schools and whose parent, guardian, or other person with legal custody is not employed within the JRCS attendance boundaries. An out- of- district transfer is required upon admission. Residency verification is required at time of application and annually thereafter*; st th We are very pleased that you are selecting JRCS as your school of choice Pre- K, Kindergarten, and 1-5 grades will be offered at our th elementary site and 6 grade will be offered at our middle school site. Tier 1 residents may enroll at any time. After Tier 1, enrollment priority is given to currently enrolled students, a legal sibling of a child currently enrolled in the School, and a child of a person directly providing educational services for the school (i.e. children of faculty/staff members employed by JRCS). Within Tier 2, additional priority will be given to applications for admission whose parent, guardian, or other person with legal custody is employed within the JRCS attendance boundaries. If, at any time, the number of eligible students applying for admission exceeds the capacity of the school/grade level, the Head of School will conduct a lottery, which shall be held within the priority level and/or grade level that is oversubscribed, to select the student(s) that may be admitted to JRCS. Enrollment and admission decisions will be based on school capacity limitations, class/grade capacity limitations, program availability, and/or educational needs of the student. *ADDITIONAL DOCUMENTATION REQUIRED: Students initially enrolling at JRCS in and in subsequent years that wish to retain their seat at JRCS, must annually complete an Intent to Re- Enroll form each spring, remain in good standing, and provide appropriate documentation to re- verify residency. Student information will be updated & siblings will be identified/enrolled. Each family must provide one of the following documents: o Proof of residency in JRCS Attendance Zone; or o Proof of residency in OKCPS School District; or o Proof of employment in JRCS Attendance Zone If a student is not able to provide these documents and they wish to continue to attend JRCS, they will be required to re- enter the lottery for their grade level. JRCS ENROLLMENT CHECKLIST: Tier 1 & 2-4 offered seats All Tiers Enrollment Forms for JRCS Driver s License Child s Birth Certificate Immunization Records Consent to Release Information (form given and signed in our office) Specific documentation: educational (IEP, 504,) or legal documentation (custody/guardianship) Tier One Residency Requirements: ADDITIONAL REQUIREMENTS BY TIER Tier Two Residency Requirements: Two (2) Proofs of Residency (e.g. Mortgage statements, leases (9 month or greater required), current utility statements- no telephone or cable statements) Current Utility Statement no telephone or cable statements For m ore information visit:

2 JOHN REX CHARTER ELEMENTARY SCHOOL ENROLLMENT FORM OFFICE USE ONLY: Received by Date: o Verified Address and Tier # o Verified Employer (if applicable) Student enrollment forms are very important for your family and for John Rex School. The information you provide allows us to: ü Distribute important school information to you including your student s academic progress reports and attendance information. ü Respond appropriately in the event of a medical situation involving your student. ü Contact you or others if there is a school emergency. Information from enrollment forms also supports students academic success by allowing the school to: ü Help your student receive support such as language services. ü Seek grants or donations to strengthen classroom instruction. ü Evaluate our work on behalf of student groups (racial/ethnic, socioeconomic, etc.). ü Ensure that we are in compliance with civil rights laws regarding students and staff. Instructions: The enrollment form is a required official record. The questions on this form ask for information that will help us provide services for your student. If you need help filling out this form, please contact us. Please print and complete all pages, then sign & date the last page. If any information should change during the school year, notify the school immediately. Student Information: Grade Entering Priority Level: q 1 q 2 q 3 q 4 * Sibling of a current student? q Yes q No Employed in Attendance Zone? q Yes q No Legal Last Name Preferred Last Name Legal Preferred _ Legal Middle Gender q Female q Male Date of Birth: / / 20 Place of Birth: City State ZIP Country Family Primary Phone # (Note: Family phone number will be used for attendance and emergency notifications) Primary Phone # ( ) Residence Address Apt. # City, OK ZIP Neighborhood School: (List, even if you do not attend this neighborhood school) Student resides primarily with: **Custodial Parent: **Important Legal Information: A legal document must be provided to the school in advance to prevent a non- custodial parent from having access to a student at school. Documentation must be kept up to date. School records may be provided to the non- custodial parent upon request, unless the school is in possession of a legal document prohibiting the non- custodial parent from receiving such records. Upon enrollment, federal and state regulations require us to gather the following information for statistical reports. If you need more information, the school can help. Ethnicity Hispanic/Latino? q Yes q No **Note: Both Ethnicity and Race must be selected Race select at least one: q American Indian or Alaska Native q Asian q Black q Native Hawaiian or Other Pacific Islander q White

3 Parent Information: Contact phone numbers and addresses will be used to distribute important school information. Parent/Guardian: q Mother q Father q Guardian q Other Legal Legal First Name Living with student? q Yes q No Permission to pick up? q Yes q No Same as Student Address q Yes q No Address (if different than above) Apt. # City State ZIP Primary Phone No. ( ) Secondary Phone No. ( ) Work Phone No. ( ) Address Employer: Address: In our attendance zone? q Yes q No Parent/Guardian: q Mother q Father q Guardian q Other (Employment verification may be required) Legal Legal First Name Living with student? q Yes q No Permission to pick up? q Yes q No Same as Student Address q Yes q No Address (if different than above) Apt. # City State ZIP Primary Phone No. ( ) Secondary Phone No. ( ) Work Phone No. ( ) Address Employer: Address: In our attendance zone? q Yes q No (Employment verification may be required) Additional Emergency Contacts: In an emergency, the parent/guardian(s) listed above will be called first. By listing a name or names in this section as an emergency contact, you are authorizing those people to pick up your student at school if you cannot be reached.

4 Program Information: In order to best serve the needs of your child, please answer the following: Does your child currently receive any special education services? q Yes q No If yes, briefly explain: Type of special education program/supports: Type of service(s): (e.g. Speech OT, PT, other) Has your child been evaluated by an outside/private agency? q Yes q No If yes, briefly explain: Does your child receive any services from an outside/private agency? q Yes q No If yes, briefly explain: Does your student have a current Individualized Education Plan (IEP)? q Yes q No If yes, attach a copy of your student s most recent IEP. If no, does your child have an expired IEP? q Yes q No If no, is your child currently being evaluated for eligibility for an IEP? q Yes q No Does your student have a current Section 504 Plan? q Yes q No If no, is your child currently being evaluated for a 504 Plan? q Yes q No Has your student already been evaluated/qualified for a Gifted & Talented program? q Yes q No Previous School(s) Attended: Last School Attended: School District: Previous School Attended: School District: Previous School Attended: School District: Is your child currently under suspension from any school or school district? q Yes q No If yes, explain: At any time, has your child ever been suspended or expelled from any school or district? q Yes q No If yes, explain: Has your child ever been advanced (skipped) a grade? q Yes q No Which grade and why? Has your child ever been retained (repeated) in a grade? q Yes q No Which grade and why? Has a school ever recommended retention for your child? q Yes q No Which grade and why? Student Medical Information: School staff needs to know if your student has a medical condition for which he/she may require assistance during the school day. Remember to advise the school of any changes in information. Doctor s Name (optional) Dentist s Name (optional) Preferred Hospital Emergency Medical Services Authority (EMSA) makes the final decision for site of best available care when serious illness, accident or other emergency event directs need for transporting to a hospital. If possible, the school will advise EMSA of your hospital preference. Insurance Carrier (optional) Last physical exam date (optional) Please check any current medical conditions: q Serious Allergies (List:) Life Threatening? q Yes q No q Diabetes q Type I q Type II q Asthma q Heart Disease q Seizure Disorder q Other special health needs at school: Medications to be taken at school: (You MUST also complete an Authorization for Medication form) List:

5 Title X McKinney- Vento Program: This program guarantees that students, no matter their living situation, have access to public education, including transportation to and from school. A school representative will be in touch if you check a box. q You are staying in a motel, car or campsite until you can find affordable housing q You are sharing housing with another family due to economic hardship q Your child is living with a relative, friend or anyone other than his/her biological parents q You are living in a shelter, temporary housing or moving from place to place without permanent housing q You are experiencing housing difficulties related to finances and would like to be contacted about services. Language Information: Does your family need an interpreter for school meetings? q Yes q No If yes, please indicate language: Other: Briefly state why you wish to have your child attend John W. Rex Charter Elementary School (optional): Sibling Information: List all siblings, even in enrolled at another school Name Age/DOB School Attending Grade Enrollment Declaration: I hereby certify I am the parent and legal guardian of, or have obtained legal guardianship through the courts for, (Student s Name). I also certify that all the information I provided in this enrollment packet is current and accurate. I certify that any false information, omissions, or misrepresentations of facts may result in rejection of this enrollment packet, revocation of a transfer, or dismissal of the enrollee. I shall submit proof of legal guardianship and/or other necessary requested documentation to complete the enrollment. Failure to do so will result in my child s enrollment being ineligible. Signature of Parent/Legal Guardian: Date: Signature of Parent/Legal Guardian: Date: John W. Rex Charter Elementary School a launch pad for learning & discovery