Enrollment Forms Packet (EFP)

Enrollment Forms Packet (EFP) Based on your student(s) grade and applicable circumstances, complete one enrollment package per student and review the information below to determine what you should submit for each student seeking admission to the IQ Academy Kansas (IQKS). You can fax, scan and email, or mail the required paperwork. *Materials Fee $70.00 for Full-Time Enrollment. Part-Time Enrollment Fee s vary depending on Part-Time Enrollment status. Please make check or money order payable to iq Academy Kansas and mail to: 320 Suset Ave Ste. B Manhattan, KS 66502. If you are paying by Credit Card, please call the Manhattan Office at: 785-539-6978 Important Note: Please send copies, do not mail the original documents iq Academy Kansas Enrollment Processing Center 2300 Corporate Park Drive Suite 200 Herndon, VA 20171 Ph. 1-877- Fx. 1-877.397.6807 Fax (preferred): Scan and Email: Mail: 1-877-397-6807 iqkansasfax@k12.com IQ Academy Kansas Enrollment Processing Center 2300 Corporate Park Drive Suite 200 Herndon, VA 20171 Required For? Item Description Provided by? Proof of Age Official Birth Certificate (not the hospital issued certificate). Immunization Record Current Immunization Record. Provided by you Proof of Residence A copy of the following: drivers license, voter registration card or utility bill. Student Information Page Parent/Guardian Information Page Emergency Contact Enrollment Agreement Please check each box, sign and submit. Media Release Please check your choice and sign. Required for all Students Records Request Residency Questionnaire Audit Agreement 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. Provided in this packet Health History Form Immunization Letter Technology Use Agreement Please initial each box, sign and submit. Computer Option Form Fee Remittance Form Required for student with an IEP or other Special Education needs IEP A copy of your student s current IEP (Individualized Education Plan). Because the IEP expires yearly, please submit the current IEP. Provided by you 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.

IQ Academy Kansas Enrollment Application 2013 2014 Academic Year STUDENT S LEGAL NAME STUDENT INFORMATION DATE OF APPLICATION: BIRTH DATE GENDER: BIRTHPLACE STUDENT CELL PHONE (w/area code): LAST SCHOOL ATTENDED: DISTRICT SCHOOL # GRADE IN 2013-14 STUDENT PERSONAL EMAIL: STUDENTS STREET ADDRESS: MONTH/YEAR ENTERED 9 TH GRADE: CITY, STATE, ZIP: SCHOOL FAX (w/area code): PROOF OF IMMUNIZATION (important: student cannot be enrolled without updated immunization records): YES NO HAS THE STUDENT EVER BEEN ENROLLED IN A SPECIAL EDUCTION PROGRAM? YES NO Please send all Special Education documents to 320 Sunset Ave, Ste B. Manhattan, KS 66502 or fax to 1-888-472-8010 IS THE STUDENT CURRENTLY EXPELLED FROM ANOTHER SCHOOL? YES NO If yes, date of expulsion: / / ETHNICITY/RACE OF STUDENT: PART A: Is the student Hispanic/Latino? (Choose only one) No, not Hispanic/Latino Yes, Hispanic/Latino: Part A (above) is about ethnicity, not race or ancestry. No matter what is selected in Part A, please answer Part B below by marking one or more boxes to indicate the student s race(s). Part B: What is the student s race? (Choose one or more) American Indian or Alaska Native Asian Black or African-American White t PART-TIME STUDENT ENROLLMENT QUESTIONS 1. Will the student participate in courses anywhere else in addition to their courses at iq Academy? Yes No If yes, where: 2. Which Courses will the student take at iqks? 3. Which Courses will the student take at the other school listed above? 4. Who can we contact at the other school regarding a shared enrollment agreement? Name: Phone#: PART-TIME ENROLLMENT FOR STUDENTS ATTENDING ANOTHER KANSAS PUBLIC SCHOOL WILL REQUIRE A SHARED ENROLLMENT AGREEMENT BETWEEN IQKS AND THE OTHER SCHOOL. Page 1

PARENT/GUARDIAN #1 CONTACT INFORMATION STUDENT S PRIMARY/LEGAL ADDRESS IS WITH: BOTH PARENTS MOTHER FATHER OTHER (please explain): PARENT/GUARDIAN NAME: RELATIONSHIP TO STUDENT: MOTHER FATHER LEGAL GUARDIAN OTHER HOME ADDRESS: ACTIVE MILITARY: YES NO Rank: Unit Name/#: CITY, STATE, ZIP: SCHOOL DISTRICT OF RESIDENCE (please note district number, e.g. USD 383): HOME PHONE (w/area code): WORK PHONE (w/area code): CELL PHONE (w/area code): PLACE OF WORK: EMAIL: PARENT/GUARDIAN #2 CONTACT INFORMATION PARENT/GUARDIAN NAME: RELATIONSHIP TO STUDENT: MOTHER FATHER LEGAL GUARDIAN OTHER HOME ADDRESS: ACTIVE MILITARY: YES NO CITY, STATE, ZIP: Rank: Unit Name/#: SCHOOL DISTRICT OF RESIDENCE (please note district number, e.g. USD 383): HOME PHONE (w/area code): WORK PHONE (w/area code): CELL PHONE (w/area code): PLACE OF WORK: EMAIL: CUSTODY INFORMATION: If parents are divorced or separated, please provide the following information. Court documentation is required. JOINT CUSTODY SOLE CUSTODY MOTHER SOLE CUSTODY FATHER SOLE CUSTODY GRANDPARENT OTHER SPECIAL CONDITIONS: Page 2

NAME: EMERGENCY CONTACT INFORMATION HOME PHONE: RELATIONSHIP: WORK PHONE: ADDRESS: CELL PHONE: NAME: HOME PHONE: RELATIONSHIP: WORK PHONE: ADDRESS: CELL PHONE: PHYSICIAN: OFFICE PHONE: DENTIST: OFFICE PHONE: REASON FOR ENROLLING IN IQ ACADEMY KANSAS Please provide any additional information so we can better meet the needs of the student ADDITIONAL INFORMATION Please provide any other information the school should know about this student PARENT/GUARDIAN SIGNATURE: DATE: Page 3

iq Academy Kansas Enrollment Agreement 2013 2014 A student enrolled in iq Academy is part of a Learning Team that includes the Student, Parent/Guardian, Teachers, the school Counselor and Learning Coach. Every member of the Learning Team is important to the student s academic success in the online learning environment. Please confirm that you agree to your role on this team by completing and initialing this Enrollment Agreement and returning it to our office. Student Name: Parent/Guardian Name: I agree that my student and I will participate in the required face to face Student and Parent Orientation at the beginning of the school year. I agree to ensure my student is meeting the state mandatory attendance requirements outlined in the iq Student Handbook. Requirements include active course participation, staying on pace, and logging in for about 1 hour per course per school day. My student will participate in state mandatory log in dates of September 4 and September 20, 2013. I agree to contact the school if my student will be absent for more than 3 consecutive days. I understand my child may be filed truant if inactive for 3 consecutive school days. I agree to ensure my student attends all state mandated testing and required proctored semester exams at regional test sites across the state. I agree to help my student create a work space that allows for quiet concentration and to help my student create a regular learning schedule to keep him or her on pace in every class. I agree to provide my student with continuous internet access and to find an alternative internet connection should home internet service be interrupted. I agree to report technical problems to the Technical Support Team immediately, in order to receive timely assistance. I agree to contact course instructors on any questions related to course content, assignments, exams or grades. I agree to work with the Learning Coach and/or Counselor if my student is falling behind in grades or pace in any or all courses. I agree to check my parent iq e mail account on a daily basis to receive communications from iq administrative staff and teachers. I agree to be an active observer for my student by logging in to my ecollege observer account and checking weekly progress reports to keep track of student activity, grades, and pace. I agree to contact the school with my telephone number or address changes in a timely manner so I will continue to receive regular communications from iq Academy Kansas. Parent/Guardian Signature: Date: Page 4

Media Release Statement iq Academy Kansas periodically uses electronic and traditional media (e.g. photographs, video or audio footage, testimonials, student art) for publicity or educational purposes. My signature on this form acknowledges the receipt of this document and understanding of the release outlined below and thus gives/denies permission for iq Academy Kansas to use such reproductions for educational and publicity purposes. Throughout the year, there are occasions when the iq Academy Kansas (iqks)and/or K12 Inc. may want to take pictures/videos of your student participating in activities related to the school. We may use, duplicate, broadcast, distribute, and display these pictures/videos in iqks or K12 Inc. publications, local newspapers, school website and/or homerooms, advertising, at iqks or K12 facilities, or on the websites maintained for them. We request that you sign this photo/video release for your student to allow us to record on film, tape, or otherwise, to edit such items as desirable or necessary, and to use the student s name, likeness, image, voice, and performance as outlined above. Thank you in advance for your support and understanding. STATEMENT OF ASSURANCE Student Media Release I have read and agree with the contents of this release. STATEMENT OF DECLINE Student Media Release I decline to give permission for any photograph, digital image, videotape, other picture, voice, comments or art to be used for promotional or educational purposes by iq Academy Kansas. Student Name: Student Signature: Parent $ Signature: $ Date: ***I $ understand that I will need to notify iq Academy Kansas if any changes to my situation occur that will impact this $ media release permission. 8I7I464JI!(*!788?A7J'4!K$b(L?(-$T&B-$&G$T&(B.A)$T&()H6A)$ I$76,-$H-6B8$.(B-HE)6(B8$6(B$6NH--$)&$G&LL&=$-6A7$&G$)7-$E)6)-C-()E$L?E)-B$?($)7-$KH-,?&.E$2$ K6N-B$?($)7-$b(L?(-$T&B-$&G$T&(B.A)>$$I$=?LL$6B7-H-$)&$6LL$K&L?A?-E$L?E)-B$6M&,-$&H$H?ED$M-?(N$ BH&KK-B$GH&C$)7-$KH&NH6C>$ (Click Here for the Online Code of Conduct Contract) 8-+)&#-!J/;&! 8-+)&#-!8%<#/-+.&! 1/.&#-LM+/.)%/#!J/;&! 1/.&#-LM+/.)%/#!8%<#/-+.&! B/-&! $ $ $ $ $ Page

Official Request for Student Records Student Information Student s Full Name: first middle last Student s Date of Birth: iq Academy Kansas Enrollment Processing Center 2300 Corporate Park Dr. Ste 200 Herndon, VA 20171 Ph. 877.345.4757 Fx. 877.397.6807 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). Grade Last Completed: Date Student was last in attendance: Did the Student Leave in Good Standing: oyes ono If no, please explain Kansas State Assesment Reporting: Math: Science: Social Studies: Homeschooled or Never Previously Enrolled in School (Fill out only if applicable) Check below if applicable: o Student was always previously homeschooled Prior School Information Name of Prior School: School s Address: street city county state zip Counselor or Registrar Signature: Sign and Date below 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). Name of Parent or Legal Guardian: first last Parent/Guardian s Signature: Date: Student Signature: (Must be 18 Years or older) SCHOOL OFFICIALS ONLY: Send student records to: Attn: Guidance Counselor, iq Academy Kansas 320 Sunset Avenue Suite B Manhattan, KS 66502 Fax: 1-888-472-8010 2011-2012 iq Academy Kansas is a middle and high school program of Manhattan-Ogden USD. Page

USD 383 Student Residency Questionnaire Name of School: iq Academy Kansas Name of Student: Birth date: Month /Day /Year Grade: Age: Gender: Male Female Ethnic Background: This questionnaire is intended to address the McKinney Vento Act, 42 U.S.C. 11435. The answers to this residency information help determine the services the student may be eligible to receive. 1. Is your current address a temporary living arrangement? Yes No 2. If YES, have you recently lost your housing or experienced an economic hardship? Yes No If you answered YES to the questions above, please complete the rest of this form. If you answered NO, please stop here. Where is the student presently living? (Check one box.) In a motel In a shelter With more than one family in a house or apartment Moving from place to place In a car, park, campsite, or other place not designated for ordinary housing Name of Parent(s)/Legal Guardian(s): Signature of Parent(s)/Legal Guardian(s): Address: Zip Code: Phone: Date: Page

Audit Information To determine school funding, the state requires an audit of mandatory attendance in September of all schools also known as Count Days. Per state legislation and the Counting Kids Manual: Virtual education students must attend stated audit/count day(s) during the month of September and/or October. Families must complete approximately 60 minutes per course on the two assigned days for the year (dates subject to the discretion of iq Academy Kansas), and they must also sign and return the resulting Academic Activity Logs. IQKS will be requiring all families that are enrolling and/or re registering to participate in this process. Failure to fully participate and submit required documentation by the designated dates will result in automatic withdrawal from iq Academy Kansas. By signing this document, it is stated that you understand the terms of the audit and will comply. This document will need to be submitted upon enrollment and/or re registration. Student s Name (please print): Student s Signature: Parent/Legal Guardian s Name (please print): Parent/Legal Guardian s Signature: Date: Date: Date Date: Page

Student Health History Health Conditions (Check all that apply) ADD/ADHD Cancer Eating Disorder Prosthesis Allergies (life Cardiovascular Endocrine Disease Seizure Disorder threatening (heart/blood Disorder) Allergies Cerebral Palsy G.I. Disorder Skin Disease Arthritis Chicken Pox Genetic Disorder Spina Bifida Asthma Cystic Fibrosis Headaches Urinary/Kidney Disease Behavioral, Dental Hearing Impaired Visually Impaired Emotional,Psychological Blood Disorder Developmental Delay High Blood Pressure Other (please list below) Brain/CNS Disorder Diabetes Musculoskeletal Name of Student: Please explain any answers checked above: Please list any medications the student takes on a regular basis: I authorize school personnel to obtain emergency medical care for my child in the event I cannot be reached. If transportation by ambulance is required, this may be obtained. Parent/Legal Guardian s Signature: Date: Page

Immunization Program Phone: 785-296-5591 Division of Health Fax: 785-296-6510 1000 SW Jackson, Ste 075 immprogram@kdheks.gov Topeka, KS 66612 www.kdheks.gov/immunize SCHOOL IMMUNIZATION REQUIREMENTS FOR THE 2012-2013 SCHOOL YEAR MARCH 2012 Immunization requirements and recommendations for the 2012-2013 school year are based on the Advisory Committee on Immunization Practices (ACIP) recommendations and the consensus of the Governor s Child Health Advisory Committee Immunization Workgroup. K.A.R. 28-1-20 defines immunizations required for any individual who attends school or early childhood programs operated by a school. http://www.kdheks.gov/immunize/download/ks_imm_regs_for_school_and_childcare.pdf Diphtheria, Tetanus, Pertussis (DTaP): five doses required. Four doses acceptable if dose 4 given on or after the 4 th birthday. A single dose of Tdap is required at Grades 7-10 if no previous history of Tdap vaccination regardless of interval since the last Td. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6001a4.htm?s_cid=mm6001a4_e%0d%0a Poliomyelitis (IPV/OPV): four doses required. Three doses acceptable. One dose required after age 4 regardless of the number of previous doses, with a 6 month minimum interval from the previous dose. Measles, Mumps, Rubella: two doses required. Hepatitis B: three doses required through grade 12. Varicella (chickenpox): two doses required for grades K-3 and 7-8; one dose required for grades 4-6 and 9-12 unless history of varicella disease documented by a licensed physician. Two doses are currently recommended by the ACIP for all ages. Haemophilus influenzae type b (Hib): three doses required for children less than 5 yrs of age in early childhood programs. Total doses needed for series completion is dependent on the type of vaccine and the age of the child when doses given. Pneumococcal conjugate (PCV): four doses required for children less than 5 yrs of age in early childhood programs. Total doses needed dependent on the age of the child when doses given. Hepatitis A: two doses required for children less than 5 years of age. The first dose is given at 12 to 18 months of age, with a 6 month interval between the first and second dose. Detailed school immunization requirements by age group are listed on the 3/01/12 version of the Kansas Certificate of Immunization (KCI). http://www.kdheks.gov/immunize/download/kci_form.pdf In addition to the immunizations required for school entry listed above, the 2012 ACIP recommendations also include the following for school children: Meningococcal (MCV4): one dose recommended at 11 years with a booster dose at 16 yrs of age; not required for school entry. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6003a3.htm?s_cid=mm6003a3_e%0d%0a Human Papillomavirus (HPV): three doses recommended for males and females at 11 years of age; not required for school entry. Influenza: yearly vaccination recommended for all ages > 6 months of age; not required for school entry. The ACIP Recommended Schedules are found at: http://www.kdheks.gov/immunize/schedule.htm The complete ACIP recommendations can be found at: http://www.cdc.gov/vaccines/pubs/acip-list.htm Efforts by schools have been central to the success of public health efforts in eliminating vaccine preventable diseases and protecting their students and families. Thank you for your dedication.

My Technology Use Agreement PLEASE READ AND COMPLETE THIS AGREEMENT IN ORDER FOR YOUR CHILD TO RECEIVE COMPUTER EQUIPMENT, SOFTWARE, AND RELATED INSTRUCTIONAL BOOKS AND MATERIALS FOR EDUCATIONAL PURPOSES FROM K12, INC. (THE SCHOOL ) INCLUDING, WITHOUT LIMITATION, FOR IQ ACADEMY AND AFFILIATED PROGRAMS. I UNDERSTAND AND AGREE THAT: (Please read and initial in the box beside each of the letters below) A. B. C. D. E. F. G. Initials All computer equipment supplied by the School (as described in the attached Terms and Conditions, the Property ) belongs to the School or its vendors and shall be returned as described in the attached Terms and Conditions, within 5 days of termination of enrollment at the School. I shall be responsible for all costs related to shipping the Property back to the School. I shall keep all packing materials provided by the School and return all Property in its original packaging, or purchase packing materials as instructed by the School. Property shall be returned within 5 days of termination of enrollment either in person to the the School office or by shipping as instructed by the School. I shall be financially responsible for the replacement cost for any loss or damage to any Property, as well as any reasonable attorneys fees and costs incurred by the School (i) in requesting the return of the Property or (ii) in seeking reimbursement for loss or damages caused to the Property while in my possession, custody or control. I agree to maintain, at my expense, insurance sufficient to cover damage to the Property by fire, theft, natural disaster, act of God, accident, or any other cause in the full replacement value of the Property. I agree to be responsible for any and all costs associated with replacing the Property regardless of the availability of insurance proceeds. The Property shall only be used for educational purposes. Installation or the attempted installation of any unauthorized software without specific permission by the School may result in fees for re imaging or for any necessary repairs. I shall inform the School within 48 hours of receipt of the Property of any discrepancies, problems or issues with the Property. I shall be responsible for notifying the office immediately of any address or contact information changes. STATEMENT of ASSURANCE Technology Use Agreement Click here for the TUA I acknowledge that that I have read, understand and agree to the provisions of this Technology Use Agreement, including the Terms and Conditions attached hereto (collectively, the Agreement ), and that if either the student for whose benefit I sign this Agreement violates the Agreement, the School may consider me in material breach and subject me to any rights and remedies available to the School under the Agreement and/or applicable law. Student Name Parent Name Date Parent Signature TERMS AND CONDITIONS Page

School Year 2013-2014 Computer Option Many of our families have expressed interest in using their own computer so they do not need to be responsible for the iq laptop. If you decide you would like to use your home computer, we will mail to you a resource CD to upload the supplemental software at no fee. (The school provided laptop is only an option for students who will be taking 4 or more courses with iqks) Please check one of the options below: My child,, will be using the school s laptop to access their schoolwork. Please fill out the 2013-2014 Technology Use Agreement and provide required insurance and parent identification. My child,, will be using his/her personal computer to access their schoolwork. My personal computer has met the minimum requirements outlined below. PC or Macintosh Hardware Requirements PC Operating System: Windows XP Service Pack 2 or Windows Vista Mac Operating System: Mac OS X 10.3 or higher 256 k of RAM or higher Sound card with speakers or a headset Internal microphone or USB microphone CD ROM or DVD drive Keyboard and mouse or compatible pointing device If you are choosing to use your home computer, please answer the following questions: Do you have a PC or Macintosh computer? What is your Operating System; i.e., Windows XP, Vista, OS X? Do you have word processing software; i.e., Microsoft Word: Parent/Guardian Name (please print): Parent/Guardian Signature: Date: Page 1

MATERIALS FEE REQUEST FORM Please submit $70.00 for Full Time Enrollment or applicable fee determined by Part Time classification by check or money order payable to: iq Academy Kansas. To submit payment by credit card, please call: 785 539 6978. Please remit payment after July 1st. (Payments received prior to July 1st will be held until July 1st) Return this form with your check or money order and include the following: Student Name Parent/Guardian Name Street Address City, State, Zip Telephone Number Check Number (Please no starter checks) MAIL TO: iq Academy Kansas 320 Sunset Avenue, Ste. B. Manhattan KS 66502 Telephone us at: 877 345 4757 if you have any questions. Page 12