Enrollment Forms Packet (EFP)

Enrollment Forms Packet (EFP) Based on r student(s) grade and applicable circumstances, complete one enrollment package and review the information below to determine what should submit for each student seeking admission to the Insight School of Minnesota (IS MN). You can fax, scan and email, or mail the required paperwork. Important Note: Please send copies, do not mail the original documents Insight School of Minnesota Enrollment Processing Center 2300 Corporate Park Drive Ste 200 Herndon, VA 20171 Ph. 800.711.5944 Fx. 855.278.8926 mn.insightschools.net Fax (preferred): Scan and Email: Mail: 1-855-278-8926 insightmnfax@k12.com Insight School of Minnesota Enrollment Processing Center 2300 Corporate Park Drive Suite 200 Herndon, VA 20171 Required For? Item Description? Proof of Age Proof of Residency Health Records/Immunization Record Official Birth Certificate (not the hospital issued certificate) 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. Current Health and Immunization Record. Report Card A copy of the most current report card for each student applying Required for all Students Release of Student Records Documentation from Current School Admin By filling out this form, are giving our school permission to request r student s official records from their previous school after the approval process. If r child was Homeschooled please indicate it on the form, fill out the top portion and sign it. Discipline/Behavior record from the previous school. *If student has current expulsion documentation, please include. Provided in this packet Open Enrollment Application Please complete this form and sign. Provided in this packet Statement of Assurance Please complete this form and sign Provided in this packet Minnesota Comprehensive Assessment Results Please submit r student s results of the MCAs Unofficial Transcripts You will need to request an unofficial transcript from r student s current school, which will show r student s academic standing. This is required in order to place all enrolling students. Once r student is approved, we will request the official transcript. Required for student with an IEP or other Special Education needs IEP Evaluation Report A copy of r 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 do not have a copy of r student s ER, can request a copy from r student s current school. Required for students that have a 504 plan 504 Accommodation Plan A copy of r student s current 504 Accommodation Plan. Because the 504 expires yearly, please submit the current 504. The Insight Schools is a program of K12 Inc. Insight Schools is a service mark of K12 Inc. version 1.1

Online Learning Expectations and Statement of Assurance for Full Time Students Insight School of Minnesota 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 online courses. This statement is intended to present students and parents the standards expected for enrollment at ISMN. As a student registering for enrollment at ISMN, 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 (current copy available at http://ismn.k12start.com/get started/): 1) Use of the internet will be appropriately used as outlined in our course materials. Inappropriate use of the internet will not be tolerated and may result in loss of the right to earn credit through ISMN. 2) Appropriate language and message content is expected at all times. Teachers and administration may retrieve and print student work, comments, and messages at any time. 3) Students are expected to adhere to the following procedure: a. Students must communicate with their online teacher(s) on a regular and consistent basis in all of their courses. Students are expected to communicate with their teacher(s) on a weekly basis. b. Students are expected to make regular and continual progress within their coursework. A general guideline is 1 2 hours per day per course. c. Students must use course materials in an authorized and appropriate manner. d. Student will be expected to follow all other rules specified by their online teacher(s). 4) Students are expected to participate in the required MN state graduation testing program. 5) Parents/guardians are expected to supervise students as part of this educational model and should assist students in meeting all school and course requirements. I have completed the open enrollment requirements to participate in this online learning program. I have reviewed the online learning program and policies in the Student Handbook and understand the expectations of online enrollment. I also understand that until this Statement of Assurance form, the online application, and the Enrollment Options Form are received by ISMN, the course registration process cannot begin. Student Name: Student Signature: Date: Parent/Guardian Signature: Date: Insight School of Minnesota 6120 Earle Brown Drive; Suite 200 Brooklyn Center, MN 55430 Phone: 763.656.2800 Fax: 763.656.2888 ismn.k12start.com

Records Release Form PARENT/GUARDIAN INSTRUCTIONS: Parents/Guardians of student under 18 years of age (or students over 18 years of age or emancipated) should print and complete all fields. Please print legibly. Completed form should be faxed to (855) 278 8926. Student name: Legal or other name, if different from above: Date of birth: Date of request: Last School attended in r district: Last District attended: District/school contact phone # PARENT RELEASE OF RECORDS (if student is under 18 years of age) I,, parent/guardian of, give permission for the release of my student s records to Insight School of Minnesota for the purpose of review. STUDENT RELEASE OF RECORDS (if student is or is over 18 years of age or emancipated) I,, give permission for the release of my records to Insight School of Minnesota for the purpose of review. Parent/Guardian/Student Signature: Date: SCHOOL/DISTRICT INSTRUCTIONS: Form and documents should be faxed to (763) 656 2888. If any documents need to be mailed or there are any questions, please contact the Insight School of Minnesota Registrar at (763) 656 2800 x2002. In order for a complete evaluation and/or educational program to be developed for this student, the agency/person listed above is permitted to exchange information that will be used in the planning process. Please refer to the Family Educational Rights and Privacy Act (FERPA) which allows disclosure without written parental consent to school officials with legitimate educational interests. These records may not be withheld for nonpayment of school fees or any other reason. Insight School of Minnesota has a legitimate educational interest and needs to review these educational records in order to develop an educational program for the above named student. INFORMATION REQUESTED (Please provide all that apply) Official transcript Discipline or behavior records Standardized test results Health records/immunization record Special Ed. records: IEP & evaluation report or 504 plan Attendance records, Title I Records, date of withdrawal, withdrawal grades & last class schedule

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) formulation for <7 yrs Tetanus and Diphtheria (Td, Tdap) formulation for >7 yrs Polio (IPV, OPV) Measles, Mumps, and Rubella (MMR) (minimum age: on or after 1 st birthday) Hepatitis B (hep B)* Varicella (chickenpox)** Pneumococcal Conjugate (PCV)*** Haemophilus influenzae type b (Hib)*** Meningococcal (MPSV4, MCV4) Human Papillomavirus (HPV) Hepatitis A (hep A) Rotavirus 1st Dose 2nd Dose 3rd Dose 4th Dose 5th Dose * Hepatitis B is required for kindergarten and 7 th grade. ** Varicella vaccine or disease history is required for kindergarten or 7 th grade. *** 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 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. Pupil Immunization Record Name Birthdate Student Number Signature of parent/guardian or physician/public clinic Date 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 Date FOR SCHOOL USE ONLY ( ) Complete; booster required in ( ) In process; 8 mos. Expires ( ) Medical exemption for ( ) Conscientious objection for 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 Date 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 Date 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 Date 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/Tdap and 3 doses of polio vaccine meets the minimum requirements of the law. Students in grades 7-12: A Td or Tdap 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. 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 10 years or older: May receive Tdap to fulfill the Td requirement for students in grades 7-12. Students 18 years of age or older: Do not need polio vaccine. Immunization Program P.O. Box 64975 St. Paul, MN 55164-0975 651-201-5503 or 1-800-657-3970 www.health.state.mn.us/immunize (12/2007) IC#140-0155

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 wish r 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): Brooklyn Center District of Choice Fax Number: 763.656.2888 Student Name (Last) (First) (Middle) Current Grade Level: Grade Level Desired: Desired Date 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 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 Please rank the schools in this non-resident district in order of preference: 1. 2. 3. enrollment year? Yes No When a spot is offered, districts will then request birthdate, records and other required registration information. If 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 Reason for request: (this does not affect r acceptance) 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. Signature Parent/Guardian Date 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 Date Application Received District Name Brooklyn Center District Contact Title Kathy Chillstrom Operations Manager District Number 0286 Telephone Number 763.656.2800 x2002 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: Insight School of Minnesota Starting Date: Grade Level: NOT APPROVED The non-resident district has denied r 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 Date

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 decide to apply, must inform r child s current school that 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. 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. not apply for school enrollment further in advance than school year that starts one year after the last January 15). After receiving approval of r application must notify the non-resident district of r 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 that r application has been accepted: Notify the nonresident district as to whether are accepting the offer of enrollment by March 1 or 15 days after notification. The nonresident district must notify the resident district that r student is changing enrollment by March 15 (or 15 days after notice from that 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. 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 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, r student is obligated to attend the nonresident district during the upcoming school year. You do not need to reapply in subsequent years for r student to remain enrolled unless move out of r current district. Note: do need to apply again for siblings. If r 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 that the only reason the application was rejected was a missed January 15 deadline. In this case, could ask r resident district whether it would be willing to form an agreement with the nonresident district for the upcoming year-- both districts must agree. However, will need to apply again next year through the regular open enrollment process, meeting the January 15 deadline, so r 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

Instructions for Completing the Application for Educational Benefits Complete an application if one or more of the following apply to r household: Any member of the household currently participates in any of these three programs: Minnesota Family Investment Program (MFIP), Food Support (SNAP), or Food Distribution Program on Indian Reservations (FDPIR). One or more children in the household are foster children (a welfare agency or court has legal responsibility for the child). Total household income (gross earnings, not take-home pay) is within these guidelines: $ Per $ Twice $ Per 2 Household Size Year $ Per Month Per Month Weeks $ Per Week 1 20,147 1,679 840 775 388 2 27,214 2,268 1,134 1,047 524 3 34,281 2,857 1,429 1,319 660 4 41,348 3,446 1,723 1,591 796 5 48,415 4,035 2,018 1,863 932 6 55,482 4,624 2,312 2,134 1,067 7 62,549 5,213 2,607 2,406 1,203 8 69,616 5,802 2,901 2,678 1,339 For each additional household member add: 7,067 589 295 272 136 Section 1 Check the box if this is the first time that have applied for meal benefits for any of r children at this school district or nonpublic school. Section 2 List all children in the household, including foster children, and provide the requested information for each child. List any regular incomes to children such as SSI payments or regular earnings. Do not list occasional earnings like babysitting. Foster children: check the foster child box for each child who is a foster child (a welfare agency or court has legal responsibility for the child). If all children who need to be approved for school meal benefits are foster children, skip sections 3 and 4. Section 3 If any member of the household receives public assistance from any of the following three programs, write in the person s name and case number: Minnesota Family Investment Program (MFIP), Food Support (SNAP), or Food Distribution Program on Indian Reservations (FDPIR). If section 3 is completed, skip section 4. A Medical Assistance number does not qualify for this purpose. Section 4 Write in all adult household members and all incomes. Include all adult persons who live in the household whether related or not. Also include any persons who are temporarily away, such as a student away at college. For earnings, list gross income before taxes and other deductions, not take home pay. You should be able to find r gross income on r pay stub. For farm/selfemployment income only, list net income after business expenses. Write in how often each income is received: Weekly (W), Bi-Weekly (every other week) (BW), Twice per Month (TM), or Monthly (M). Do not write in an hourly wage. Examples of other income to include in the last column are farm or self-employment income, Veterans (VA) benefits, and disability benefits. Do not include as income: foster care payments, federal education benefits, or assistance provided by MFIP, Food Support (SNAP), WIC or FDPIR. Military: Do not include income from the Military Privatized Housing Initiative or combat pay. Section 5 Leave these boxes blank if want to share r school meal eligibility status with these health benefit/insurance programs. Check the boxes if do not want to share r eligibility status with these programs. Section 6 The form must be signed by an adult household member. If section 4 of the application has been completed, the signer must provide the last four digits of their Social Security number unless they indicate that they do not have a Social Security number. Provide address and phone number to assist in processing r application. Also please provide voluntary racial/ethnic information requested on the back page of the form.

Application for Educational Benefits Free and Reduced-Price School Meals School Year 2013-14 State and Federally Funded Programs 1. Check here if this is the first school meal application at this school district or nonpublic school for any child listed below. 2. Names of all Children in Household including Foster Children Attach additional page if necessary Date of Birth Month/Day/Year G r a d e School if foster child * Any Regular Income to Child (for example SSI) Last Name First Name * The child is the legal responsibility of a welfare agency or court. If all children applied for are foster children, skip Sections 3 and 4. 4. Names of all Adults in Household (all household members not listed in Section 2) Include all adults living in r household, related or not. Attach additional page if necessary. Last Name First Name Check if NO Income Household Incomes: Write in each gross income and how often it is received: weekly (W), bi-weekly (every other week) (BW), twice per month (TM), monthly (M). Do not write in hourly pay. If income fluctuates, write in the amount normally received. Attach additional page if necessary. Gross Wages and Salaries - all jobs - before deductions - Pension, SSI, Retirement, Social Security Public Assistance, Child Support, Alimony Unemployment, Worker s Comp, Strike Benefits Any Other Income, including net Farm/ Self-Employment $ per $ per $ per $ per $ per $ per $ per $ per $ per $ per $ per $ per $ per $ per $ per 5. If r children are approved for school meal benefits, this information may be shared with MinnesotaCare and General Assistance Medical Care programs to identify children eligible for Minnesota health insurance programs. See back page for more information. Leave the boxes blank to allow sharing of information. Do not share information with the MinnesotaCare health insurance program. Do not share information with the General Assistance Medical Care program. 6. 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 and state funds based on the information I give. I understand that if I purposely give false information, my children may lose meal benefits and I may be prosecuted. Signature of Adult Household Member (required) Print Name: Date: Social Security number last 4 digits (required if Section 4 is completed): OR I don t have a Social Security number Address: City Zip Home Phone: Work Phone: Total Household Size: Total Incomes: $ per Approved (check all that apply): Case Number - Free Foster - Free Income Free Income Reduced Price Temporary until Denied: Incomplete Income Too High Other: Signature - Determining Official: Date: Change Status To: Reason: Withdrawn: 3. Benefits (if applicable) If any household member receives benefits from a program listed below, check the applicable box and write in the name of the person receiving benefits and their case number. Skip section 4. Name Case Number Minnesota Family Investment Program (MFIP) Food Support (SNAP) Food Distribution Program on Indian Reservations - Medical Assistance number does not qualify.- Signature Confirming Official: Date: Date Verification Sent: Response Due: 2 nd Notice: Result: No Change Free to Reduced-Price Free to Paid Reduced-Price to Free Reduced-Price to Paid Reason for Change: Income Household Size Refused Cooperation Other: Signature Verifying Official: Date:

Privacy Act Statement / How Information Is Used The National School Lunch Act requires that the household member signing the application must provide the last four digits of their Social Security Number unless an active Minnesota Family Investment Program (MFIP), Food Support (SNAP) or Food Distribution Program on Indian Reservations (FDPIR) assistance number is supplied for r child, or are applying for a foster child, or do not have a Social Security number. Provision of a Social Security number is not mandatory, but if a Social Security number is not given or an indication is not made that the signer does not have such a number, the application cannot be approved. We will use r information to determine if r child is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. We may share r 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. At public school districts, each student's eligibility status is also recorded on a statewide computer system used to report student data to the Minnesota Department of Education as required by state law. The Minnesota Department of Education uses this information to: (1) administer state and federal programs; (2) calculate compensatory revenue for public schools; and, (3) judge the quality of the state's educational program. Sharing Information with MinnesotaCare and General Assistance Medical Care Programs Children who are eligible for free and reduced-price school meals may be eligible for Minnesota health insurance programs. Your child s eligibility status for school meals (qualified for free or reduced-price meals) may be shared with the MinnesotaCare and General Assistance Medical Care programs unless tell us not to share r information by checking the boxes in section 5 of the application. You are not required to share information for this purpose and r decision will not affect approval for school meal benefits. Nondiscrimination Statement This explains what to do if believe have been treated unfairly: In accordance with federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer. Children s Ethnic and Racial Identities (Optional) Please provide the following information, which is used to determine the institution s compliance with civil rights laws. If the information is left blank, a representative of the institution is required to identify the ethnic and racial categories of participants for civil rights reporting. 1. Choose one ethnicity: Hispanic/Latino Not Hispanic/Latino 2. Choose one or more (regardless of ethnicity): Asian American Indian or Alaskan Native Black or African American Native Hawaiian or other Pacific Islander White