Enrollment Forms Packet (EFP) 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 email, or mail the required paperwork. Important Note: Please send copies, do not mail the original documents Fax (preferred): Scan and Email: Mail: 1-877-554-1090 MNVAfax@k12.com 2300 Corporate Park Dr. Ste 200 Herndon, VA 20171 Reminder: You must create an account with K12 before submitting paperwork (https://myaccount.k12.com) 2300 Corporate Park Dr. Ste 200 Herndon, VA 20171 Ph. 1.877.554.1081 Fx. 1.877.554.1090 www.k12.com/mnva Required For? Item Description Provided by? Proof of Age Official Birth Certificate (not the hospital issued certificate) Proof of Residency Current Utility bill showing service address OR Mortgage/Rental statement including signature page (please note documents with a PO Box address will not be accepted) OR Tax Statement. Report Card A copy of the most current report card for each student applying (except if appling into Kindergarten). Release of Student 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. Required for all Students Non-Resident Agreement Open Enrollment Application This is a required document for all students, EXCEPT those that currently reside in the Houston School District (#294) Please complete this form and sign. Resident District Information Complete and submit. Outing and Event Permission Form Please complete this form and sign. Minnesota Comprehensive Assessment Results Please submit your student s results of the MCAs (4th-12th graders Only) MDH Pupil Immunization Record Your student s physician will need to complete and sign this form Required for Students Entering Kindergarten Registration Form/ Early Childhood Screening Please complete this form and submit Required for grades K-8 Online Learning Expectations/Statement of Assurance Please complete this form and sign Required for grades 9-12 Transcripts Full-Time Student Contract You will need to request an unofficial transcript from your student s current school, which will show your student s academic standing. This is required in order to place all 10th-12th graders enrolling. Once your student is approved, we will receive the official transcript. For 9th graders, please submit the most recent Report Card. Both the Legal Guardian and student must read and sign this agreement. Required for student with an IEP or other Special Education needs IEP Evaluation Report A copy of your student s current IEP (Individualized Education Plan). Because the IEP expires yearly, please submit the current IEP. The Evaluation Report is valid for 3 years. If you do not have a copy of your student s ER, you can request a copy from your student s current school. Required for 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.
NON-RESIDENT AGREEMENT FORM Student s Last Name First Name Middle Name Student s Address (include apt. # if applicable) City/State/Zip Parent or Guardian Last Name First Name Phone Parent Address (if different than student s) Apt. # City/State/Zip Seeking enrollment for school year: For what grade? Grade as of application date: Reason for requested transfer: Non-Resident (Serving) School District: Houston Public School Resident School District Name: Signature of Parent/Guardian: District # 294 District # School Requested: Student Moved if applicable MNVA Month Day Year School Most Recently attended: X The above information is true and correct to the best of my belief and knowledge. Signed 1. Type of Transfer: (Completed by Resident District Staff) Agreement Between School Boards, Enrollment Exceptions. M. S. 124D.08, Subd 1-2: Transfer requires the approval of both school districts. (SAC Code 11). 2. Continued Enrollment of 11th and 12th Grade Students. M. S. 124D.08, Subd 3: Transfer requires the approval of the non-resident school district only (SAC Code 04). 3. Graduation Incentives Program. M. S. 124D.68: Transfer requires the approval of the non-resident school district only (SAC Code 03). Effective date of transfer Expiration date of transfer (mm/dd/year): (mm/dd/year): Non-Resident (Serving) School District: X Signature of Superintendent or Responsible Authority Resident School District: X Signature of Superintendent or Responsible Authority Signed Signed Application APPROVED Application DENIED Application APPROVED Application DENIED
2300 Corporate Park Dr. Ste 200 Herndon, VA 20171 Release of Student Records Ph. 1.877.554.1081 Fx. 1.877.554.1090 www.k12.com/mnva 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/immunization, and discipline/expulsion records). Student Information Student s Full Name: first middle last Student s of Birth: Student s Social Security Number: 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: ( ) Name of Parent or Legal Guardian: first last Parent/Guardian s Signature: : SCHOOL OFFICIALS ONLY: Send student records to: 306 West Elm Street Houston, MN 55943 Student s Name: Student s Home Phone: 11
2300 Corporate Park Dr. Ste 200 Herndon, VA 20171 Full-Time Student Contract Ph. 1.877.554.1081 Fx. 1.877.554.1090 www.k12.com/mnva The (MNVA) provides students an opportunity to participate in online learning on a full-time basis. Because online learning represents a non-traditional learning experience, there are certain expectations for students enrolling in these courses. This contract is intended to present to students and parents the standards expected for enrollment in the MNVA program. As a student registering for the MNVA program, I am aware that I am expected to comply with the following standards as well as all policies and procedures set forth in the Student Handbook: 1. The use of the Internet will be appropriately used as outlined in the course materials. Inappropriate use of the Internet will not be tolerated and may result in the loss of the right to participate in the MNVA program. 2. Appropriate language and message content is expected at all times. Teachers may retrieve and print student work, comments, and messages at any time. 3. Students are expected to adhere to the following procedures: a. Students must communicate with their online teacher(s) on a regular and consistent basis in all of their classes. Students are expected to communicate with their teachers on a weekly basis. b. Students must log into all of their online courses on a regular and consistent basis. Students are expected to work in their classes a minimum of five times per week. c. Students must use course materials in an authorized and appropriate manner. d. Students will be expected to follow other rules specified by their online teacher. Students who fail to comply with the above conditions are subject to: First Offense: Second Offense: The student will receive an email warning from either his/her online teacher or the MNVA administration. A copy of the email will be sent to the student s parents. A conference will be held with the student, the student s parent/guardian, and the administrative staff of MNVA regarding the student s continuation with the MNVA program. Any student discipline for program removal will be in compliance with the Pupil Fair Dismissal Act, Rev. 2007. I have completed the open-enrollment requirements to participate in this online learning program. I have read the policies in the Student Handbook and agree to this Student Contract. I also understand that until this contract and the Student Application are received by the, the course registration process cannot begin. Student Name: Student Signature: : Parent/Guardian Signature: : Student s Name: Student s Home Phone: 12
Houston Public Schools 306 South Elm Street Houston, Minnesota 55943 Ph: 866 215 2292 www.houston.k12.mn.us Online Learning Expectations, and Statement of Assurance The (MNVA) provides students an opportunity to participate in online learning on a full-time basis. Because online learning represents a non-traditional learning experience, there are certain expectations for students enrolling in these courses. This contract is intended to present to students and parents the standards expected for enrollment in the MNVA program. As a student registering for the MNVA program, I am aware that I am expected to comply with the following standards as well as all policies and procedures set forth in the Student Handbook: 1. The use of the Internet will be appropriately used as outlined in the course materials. Inappropriate use of the Internet will not be tolerated and may result in the loss of the right to participate in the MNVA program. 2. Appropriate language and message content is expected at all times. Teachers may retrieve and print student work, comments, and messages at any time. 3. Students are expected to adhere to the following procedures: a. Students must communicate with their online teacher(s) on a regular and consistent basis in all of their classes. Students are expected to communicate with their teacher(s) on a weekly basis. b. Students in grades 1-8 must log into all of their online courses on a regular and consistent basis. Students are expected to work in their classes a minimum of five times per week for an average of 5-6 hours of coursework per day. Kindergarten students should average 2 ½ hours of coursework per day. c. Students are expected to make regular and continual progress within their coursework. d. Students must use course materials and computer hardware in an authorized and appropriate manner. e. Students will be expected to follow all other rules specified by their online teacher(s) and outlined in the Student Handbook. 4. Students are expected to participate in the required state testing program, as well as any school testing requirements. 5. Parents/guardians are expected to supervise students as part of this educational model. Parents/guardians should assist students in meeting all school requirements, such as work sample submission and attending regular student/teacher interactions. I have completed the open-enrollment requirements to participate in this online learning program. I have reviewed the online learning program and the policies in the Student Handbook and understand the expectations of online learning enrollment. I also understand that until this Statement of Assurance form and the Online Student Application are received by the, the enrollment application cannot be accepted and finalized. Student Name: Student Signature: : Parent Signature: : LEADING IN LEARNING
2300 Corporate Park Dr. Ste 200 Herndon, VA 20171 Resident District Information Ph. 1.877.554.1081 Fx. 1.877.554.1090 www.k12.com/mnva To Be Completed By The Student or Parent: Student s Name: Last grade attended: Indicate dates attended: Parent s Name: Street Address: City, State, Zip: Parent s Phone: Resident School District Name: Resident School District Number: Res. School City, State Zip: Student s Name: Student s Home Phone: 13
Houston Public Schools 306 South Elm Street Houston, Minnesota 55943 Ph: 866 215 2292 www.houston.k12.mn.us MNVA Outing and Event Permission Form 2011-2012 The following student has my permission to attend sponsored outings and events for the 2011-2012 school year: Student Name: When warranted, I entrust my child to the care of the MNVA teacher(s) sponsoring the event. Whenever my child is left in the care of an MNVA staff member, I agree to leave emergency contact information at the time of each outing. Illness, Injury & Insurance In case a student is ill or injured at a site or activity, MNVA staff shall have the authority to take appropriate action to provide immediate medical care and/or ambulance service. Every reasonable effort will be made to contact the parents to obtain their approval prior to a decision to transport a student to a doctor s office or hospital emergency room. However, unless the parent is able to come to the site immediately to attend to the child personally, MNVA staff shall have the authority to decide on a course of action and notify the parents as soon as possible. Financial responsibility for hospital and medical care and/or ambulance service shall be assumed by the parents. Parents will be asked to provide MNVA staff with a telephone number to be used in case of an emergency. This should be the number of a close relative or the number of the parent s place of employment. Medical Conditions: Does your child have any special medical conditions: drug or food allergies, diabetes, etc? If not, circle NO. If yes, circle circle YES and explain the special medical conditions. YES NO Explain: Emergency Contacts: (Names will be kept on file) PLEASE PRINT Name Relationship Number Name Relationship Number Print Name of Parent/Guardian: Signature of Parent/Guardian: : LEADING IN LEARNING
Early Learning Services 1500 Highway 36 West Roseville, MN 55113-4266 REGISTRATION FORM FOR EARLY CHILDHOOD SCREENING ED-02390-01 GENERAL INFORMATION AND INSTRUCTIONS: The following registration form needs to be completed by the parent/guardian of the child. Please print the information. CHILD IDENTIFICATION INFORMATION Child s Legal Name (First, Middle, Last) Child s Nickname or Other Name (First, Middle, Last) Child s Birth Race/Ethnicity (Check one) Gender Male Female 1 - American Indian 3 - Hispanic 5 - White, not of Hispanic Origin 2 - Asian or Pacific Islander 4 - Black, not of Hispanic Origin PRIMARY/SECONDARY LANGUAGE INFORMATION Which language did your child learn first? Which language is most often spoken in your home? Which language does your child usually speak? English English English Other (specify): Other (specify): Other (specify): PREVIOUS HEALTH & DEVELOPMENTAL SCREENING INFORMATION Has your child received a comprehensive health and developmental screening as a preschooler (3-5 years old)? Yes No If Yes, screening date: Has your child ever been evaluated for special education or ever received special education services through an Individual Education Plan (IEP), Individual Family Services Plan (IFSP) or Individual Interagency Intervention Plan (IIIP)? Yes No PARENT/GUARDIAN VERIFICATION OF INFORMATION I hereby verify that the above information is true and correct to the best of my knowledge. Name (printed) Parent/Legal Guardian Signature - Parent/Legal Guardian - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - TO BE FILLED OUT BY SCHOOL DISTRICT PERSONNEL ONLY Screening Screening District Name District Number & Type Child s Resident District Name District Number & Type MARSS I.D. Number Check type of screening child received STATE AID CATEGORY (SAC): 41 - Screening by District 43 - Head Start 45 - Conscientious Objector 42 - Child & Teen Check-ups/EPSDT 44 - Private Provider SCHOOL DISTRICT VERIFICATION OF INFORMATION I hereby verify that the above information is true and correct to the best of my knowledge. Signature - School District Coordinator
Statewide Enrollment Options Form Required form for all Minnesota districts PARENTS: Email, mail or fax this form to the superintendent s office of the non-resident district where you wish your student to attend. Do not mail to the Minnesota Department of Education. See General Information and Instructions for important January 15 th deadline information that may apply. Section 1: To be completed by the Student s Parent/Guardian Parent/Guardian Name (Last) (First) (MI) Telephone Number Home: ( ) Work: ( ) Parent/Guardian Address: City/State/ZIP: Resident District: City: District of Choice (Non-Resident School District): District of Choice Fax Number: ( ) Student Name (Last) (First) (Middle) Current Grade Level: Grade Level Desired: Desired of Enrollment: Is this student currently expelled under Minn. Stat. 121A.45 for a reason listed in Minn. Stat. 124D.03, Subd. 1? Yes No Are you a Minneapolis resident interested in The Choice is Yours Program? Yes No Don t know Age of Student Will the student be at least age 5 and under age 21 by September 1 of enrollment year? Yes No When a spot is offered, districts will then request birthdate, records and other required registration information. If you answered NO to the statement, the student is not eligible for open enrollment unless the student fully meets the requirements for an exception to the age requirements listed in the instructions. Yes, this student qualifies under the terms of the exceptions described on the back of this form. I hereby verify that the above information is true and correct to the best of my knowledge and belief. Please rank the schools in this non-resident district in order of preference: 1. 2. 3. Reason for request: (this does not affect your acceptance) Signature Parent/Guardian Non-Resident District: Complete Section 2. Notify parents/guardians by February 15 (or no more than 30 days after receiving applications that come later) of approval or disapproval of application. Families must accept or decline the offer by March 1 or 15 days later. After receipt of commitment to attend, the non-resident district must notify the resident district by March 15 (or 60 days after initial receipt if form filed after January 15) of the student s intent to enroll. Report all rejected applications to the Minnesota Department of Education by July 15. Section 2: To be completed by the Non-Resident District Application Received District Name District Number District Contact Title Telephone Number ( ) APPROVED On the basis of information provided in the above application, and with respect to district policies and procedures, the above student will be assigned for enrollment at: School Building Name: Starting : Grade Level: NOT APPROVED The non-resident district has denied your request for open enrollment because of the following reason(s) allowed in Minn. Stat. 124D.03. Check all that apply. 1. The January 15 deadline applies and was not met; situations that would have waived the deadline are not present. See General Information and Instructions or Minn. Stat. 124D.03, Subd. 3. 2. Statute enrollment has been reached; Minn. Stat. 124D.03, Subd. 2. 3. Grade is closed district-wide by board action; Minn. Stat. 124D.03, Subd. 2. and Subd. 6. 4. District has denied the application because of expulsion reasons; Minn. Stat. 124D.03, Subd. 1. NON-RESIDENT DISTRICT SIGNATURE: Superintendent / Responsible Authority
GENERAL INFORMATION AND INSTRUCTIONS: Kindergarten through twelfth grade students and pre-kindergarten children with disabilities may apply to attend a public school outside of their resident district (Minn. Stat. 124D.03). Use one application per student per requested district. Parent/Guardian: Before making a selection it would be beneficial to request school and program information from districts, visit schools, and ask questions of administrators, teachers, parents and students. The Minnesota Department of Education s (MDE) Website: http://education.state.mn.us has information about school districts, schools and programs. Once you decide to apply, you must inform your child s current school that you are applying to a nonresident district for enrollment. Complete Section 1 and sign Section 2 of the School District Enrollment Options Program form and send the completed application to the non-resident district s superintendent s office. Please do not send the form to MDE. Age requirements: Open enrollment is only available to students who will be age 5 by September 1 and under age 21, without a high school diploma, unless: The student is under age 5 and has been identified through a formal assessment process in the resident district as needing an individual education plan for early childhood special education. In these situations, the family should list EC as their requested grade level OR, the student has met all requirements of the nonresident district for consideration for early entrance to kindergarten such as a September or October birth date, assessment testing and a trial period of enrollment and the nonresident district has agreed to consider an open enrollment for the child for early entrance to kindergarten. Do not submit this form in this situation without first working with the nonresident district to determine eligibility. not apply for school enrollment further in advance than school year that starts one year after the last January 15). After receiving approval of your application you must notify the non-resident district of your commitment to attend by March 1 or 15 days after applying. School districts who have more applications than they can accommodate hold lotteries to determine which students will receive spots. If the nonresident district notifies you that your application has been accepted: Notify the nonresident district as to whether you are accepting the offer of enrollment by March 1 or 15 days after notification. The nonresident district must notify the resident district that your student is changing enrollment by March 15 (or 15 days after notice from you that you are accepting the enrollment if January 15 application deadline was not applicable). Visit the district offices at least 10 days prior to the above starting date for completion of all enrollment forms. Deadlines and exceptions to deadlines: Applications must be sent to the nonresident district by January 15 in order to enroll beginning the following school year unless: one or both districts receives Statewide Integration Revenue, in which case there is no deadline and enrollment may begin at any time. (Minn. Stat. 124D.03, Subd. 4) OR, the student moved into the resident district on or later than December 1. (Minn. Stat. 124D.03, Subd. 7). OR, other unusual situations apply under Minnesota Statutes 124D.03, Subd. 7. Acceptance of Open Enrollment cannot be based on previous academic achievement, athletic or other extracurricular ability, disabling conditions, proficiency in the English language, previous disciplinary proceedings or the student s district of residence. (Minn. Stat. 124D.03, Subd. 6.) Families may indicate preferences for school sites or programs within the district; if unavailable, districts will offer families options at other sites unless the grade level or open enrollment has been closed by board action. However, families may apply in more than one district. Use one form per child per district. Do not disclose special needs of students on the School District Enrollment Options Programs form; this information is provided after an enrollment spot is offered. Minneapolis Families: The Choice is Yours program provides families who live in the city and meet income guidelines the chance to attend suburban schools with free transportation. See http://foodservice.mpls.k12.mn.us/free_and_reduced_price_meal_eli gibility.html for income guidelines and http://www.wmep.k12.mn.us/aboutciy.html for more about The Choice is Yours. Parents or guardians of students with special needs are encouraged to contact the district as soon as possible after accepting an offer of enrollment in a nonresident district so an I.E.P. team can be convened. The school district will provide you information regarding transportation. (Minn. Stat. 123B.88, subdivision 6, Minn. Stat. 124D.03, Subd. 8.) Minneapolis families who meet income guidelines and attend suburban districts through The Choice is Yours may qualify for free transportation. By accepting this enrollment, your student is obligated to attend the nonresident district during the upcoming school year. You do not need to reapply in subsequent years for your student to remain enrolled unless you move out of your current district. Note: you do need to apply again for siblings. If your application was denied, districts: Must indicate the provision in state law that applied. Must report to the Minnesota Department of Education by July 15 all denied applications. May inform you that the only reason the application was rejected was a missed January 15 deadline. In this case, you could ask your resident district whether it would be willing to form an agreement with the nonresident district for the upcoming year-- both districts must agree. However, you will need to apply again next year through the regular open enrollment process, meeting the January 15 deadline, so your student s enrollment is not subject to year-to-year mutual agreements between districts. (Minn. Stat. 124D.03, Subd. 6 Currently expelled students: Nonresident districts may, but are not required to, reject applications from students currently expelled as defined in Minnesota Statutes 121A.45 and Minnesota Statutes 124D.03 Subd 1. Notice as to acceptance of application: You can expect to receive an approval/disapproval from the nonresident district by February 15 or 30 days after applying for the current or upcoming school year. (Do
Pupil Immunization Record Name Birthdate Student Number FOR SCHOOL USE ONLY ( ) Complete; booster required in ( ) In process; 8 mos. expires ( ) Medical exemption for ( ) Conscientious objection for Minnesota Statutes Section 121A.15 requires children enrolled in a Minnesota school to be immunized against certain diseases, allowing for specified exceptions. This form is designed to provide the school with information required by the law. Enter the MONTH, DAY, and YEAR for all vaccines the pupil received. DO NOT USE ( ) or ( ). Vaccines/doses in shaded boxes are recommended but not required by law. Type of Vaccine Diphtheria, Tetanus, and Pertussis (DTaP, DTP) Diphtheria and Tetanus (DT) - pediatric formulation (<7 yrs) Tetanus and Diphtheria (Td) adult formulation (7yrs) Polio (IPV, OPV) Measles, Mumps, and Rubella (MMR) (minimum age: 12 mos) Hepatitis B (hep B) * Varicella (chickenpox)** Pneumococcal Conjugate (PCV)*** Haemophilus influenzae type b (Hib)*** 1st Dose 2nd Dose 3rd Dose 4th Dose 5th Dose Mo/Day/ Yr Mo/Day/Yr Mo/Day/Yr Mo/Day/Yr Mo/Day/Yr * Hepatitis B is required for kindergarten and 7 th grade. ** Varicella vaccine will be required starting fall 2004. *** PCV and Hib vaccines are recommended only for children through age 4 years. Note for school personnel: Be sure to initial and date any new information that you add to this form after the parent/guardian submits it. Also, record combination vaccines (e.g., DTaP+Hib, Hib+HBV) in each applicable space. Indicate immunization status and source of above information by choosing one of the following: I certify that this student has received all immunizations required by law. Signature of parent/guardian or physician/public clinic I certify that this student has received at least one dose of vaccine for diphtheria, tetanus, and pertussis (if age-appropriate), polio, hepatitis B (K + 7 th ), varicella (K + 7 th ), measles, mumps, and rubella and will complete his/her diphtheria, tetanus, pertussis, hepatitis B, and/or polio vaccine series within the next 8 months. The dates on which the remaining doses are to be given are: Signature of physician/public clinic Medical exemption: No student is required to receive an immunization if they have a medical contraindication or laboratory evidence of immunity. To receive a medical exemption, a physician must sign the following statement: I certify that immunization is contraindicated for medical reasons or that laboratory confirmation of adequate immunity exists for the following immunizations: Signature of physician Conscientious exemption: No student is required to have an immunization which is contrary to the conscientiously held beliefs of his/her parent or guardian. To receive this exemption, a parent or legal guardian must complete and sign the following statement and have it notarized: I certify by notarization that immunization for my child is contrary to my conscientiously held beliefs. Indicate vaccine(s): Signature of parent or legal guardian Subscribed and sworn to before me this day of 20 Signature of notary History of varicella disease: I certify that this child had chickenpox disease on this date: (YR) and therefore does not need a varicella shot. Signature of parent/legal guardian or physician/public clinic Additional exemptions Children less than 7 years of age: The 5 th dose of DTaP/DTP/DT (similarly, the 4 th dose of polio vaccine) is not necessary if the 4 th DTaP/DTP/DT (3 rd dose of polio) was administered after the 4 th birthday. Children 7 years of age and older: A history of 3 doses of DTaP/DTP/DT/Td and 3 doses of polio vaccine meets the minimum requirements of the law. Students in grades 7-12: A Td booster at age 11 years or later is not required for students in grades 7-12 whose most recent Td was given after their 7 th birthday but before their 11 th birthday. Instead, it will be required 10 years after the date of the most recent dose. Enforcement of thetd booster requirement will be reinstated in the fall of 2004 for all 7 th -12 th graders. Students 11-15 years of age: A 3 rd dose of hepatitis B vaccine is not required for those students who provide documentation of the alternative 2-dose schedule. Students 7 years of age or older: Do not need pertussis vaccine. Students 18 years of age or older: Do not need polio vaccine. IC#140-0155 HE #01574-05 (MDH, 6/2004)