Enrollment Forms Packet (EFP) - PDF Free Download

Enrollment Forms Packet (EFP) Please use this coversheet to reference all the forms and information needed to complete this step in the enrollment process. Based on your student(s) grade and applicable circumstances, you are required to submit documentation outlined below. You can fax, scan and e-mail, or mail the required paperwork (Please send copies, do not mail the original documents.) Important Note: Please send copies, do not mail the original documents Fax (preferred): Scan and Email: Mail: 1-877-397-6810 iqminnesotafax@k12.com iq Academy Minnesota Enrollment Processing Center 2300 Corporate Park Drive, Ste 200 Herndon, VA 20171 Reminder: You must create an account with K12 before submitting paperwork (https://myaccount.k12.com) *Please save your account login information in a safe place you will use later to start school Required For? Item Description Provided by? Required for all Students Required for Students Entering Kindergarten Proof of Age Official Birth Certificate (not the hospital issued certificate) Provided by you Proof of Residency Release of Student Records Student Contract MDH Pupil Immunization Record MDE Open Enrollment Application Registration Form/ Early Childhood Screening Current Utility Bill (gas, water, electric, sewage, cable or land line phone) with service address OR Mortgage statement/current Lease with signature (please note: documents with a PO Box address will not be accepted) OR Tax Statement 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. Please complete this form and sign. Please complete this form and sign Please complete this form and sign. Please complete this form and submit Provided by you Provided in this packet Provided in this packet Provided in this packet Provided in this packet Provided in this packet *****This section outlines the records that will be requested from your previous school upon receipt of the above required documents. Students will not be able to complete the enrollment process until all school records have been received.***** Required for grades 10th-12th Required for student with an IEP or other Special Education needs Required for students that have a 504 plan Transcripts Minnesota Comprehensive Assesment Results IEP Evaluation Report 504 Accommodation Plan Copy of student s high school transcript. Students in grades 10-12 will not be able to choose courses until a transcript is received and a Credit Inventory has been completed by iq Office Staff. Copy of student s results from MCAs (High School: Writing, Reading, Science Math) 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. A copy of your student s current 504 Accommodation Plan. Because the 504 expires yearly, please submit the current 504. iq Academy Minnesota Enrollment Processing Center 2300 Corporate Park Drive, Ste 200 Herndon, VA 20171 Ph. 1.877.994.4766 Fx. 1.877.397.6810 icademymn.org Previous School (we may ask for YOUR help in locating records that are not received upon request)

*Legal Guardian paperwork must be submitted if someone other than the parent is signing forms Release of Student Records iq Academy Minnesota 2300 Corporate Park Dr. Ste 200 Herndon, VA 20171 Ph. 1.877.994.4766 opt# 3 Fx. 1.877.397.6810 www.iqacademymn.org Please accept this document as formal approval for the release of all official school records (including transcripts, testing information, special education, health/immunization, and discipline/expulsion records.) Student Information Student s Full Name: first middle last Student s Date of Birth: Student s Home : Student s Legal Address: street apt# city county state zip Prior School Information Name of Prior School: School Address: street apt# city county state zip School Phone: School Fax: Last Date Attended: Grades Attended: YES NO Has this student ever been homeschooled in grades 9 12? If yes, please submit homeschool transcript. YES NO Has this student ever attended another high school other than the prior school in grades 9 12? If yes, please list school/grade level. YES NO Does your student have a current IEP or 504 plan that needs to be requested? If yes, these records must be received prior to course selection. Parent/Guardian Information Parent/Guardian Full Name: last first Parent/Guardian Signature: Date: *Legal Guardian paperwork must be submitted if someone other than the parent is signing SCHOOL OFFICIALS ONLY: Send ALL the following records: Send student records to: iq Academy Minnesota *Course Grades to Date (if term is in session) 601 Randolph Ave *Transcript of Earned Credit Fergus Falls, MN 56537 *Minnesota State Assessment Scores Fx: 1 866 486 8948 *Immunization/Health Records Ph: 1 218 998 3198 *IEP & Evaluation Report *MARSS # : Student s Name: Student s Home Phone: 2

iq Academy Minnesota 2300 Corporate Park Dr. Ste 200 Herndon, VA 20171 Ph. 1.877.994.4766 opt# 3 Fx. 1.877.397.6810 www.iqacademymn.org *Legal Guardian paperwork must be submitted if someone other than the parent is signing Full-time Student Contract iq Academy Minnesota (IQMN) 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 that students and parents must agree to before enrolling in courses delivered online. This contract is intended to outline expectations for students and parents enrolled in the iqmn program. A copy of the iq Academy Minnesota Handbook referenced below can be found online at: www.iqmn.org/handbook As a student and parent enrolling in the IQMN program, I am aware that I am expected to comply with the following policies and procedures set forth in the Student Handbook: 1. Enroll in courses ONLY with iq Academy Minnesota because this is a full-time enrollment application. 2. Reside in the state of Minnesota, not leaving for more than 15 consecutive days in order to remain eligible for public school funding. 3. Have access to a high-speed internet connection in home at all times during enrollment. 4. Have access to a back-up computer and internet access should the primary computer hardware/internet fail to work. 5. Communicate with appropriate language and message content as outlined in the Online Code of Conduct (School Work section of the iq Academy Minnesota Handbook.) Inappropriate use of the Internet will not be tolerated and may result in the loss of the right to participate in the iqmn program. 6. Assist in locating all documents outlined on page 1 of this application are on file with iqmn. The course registration process will not begin until all required documents are received. 7. Participate in all grade level State Assessments mandated by the Minnesota Department of Education and other required school testing. Provide time and transportation needed to attend the proctored location, up to 2 hours away. 8. Request a course withdraw up to 15 days after being assigned to the course. After the 15 day period, the course will remain in the student s schedule and earn a grade on the report card or transcript. 9. Attend weekly Class Connect sessions (live or recorded) that are scheduled by the teacher and could take place during the day or evening (8am to 8pm.) Participation in weekly sessions is 10% of the student s course grade. 10. Communicate changes in contact information such as phone, address, or e-mail to the IQMN office immediately. 11. Maintain regular weekly attendance measures outlined in the Attendance and Truancy section of the handbook and participate in all courses each week. 12. Parents/guardians are expected to supervise students as part of this educational model, assuring the work is being completed on-time and adequate attendance measures are being attained on a weekly basis. The signature below is assurance that you have read and understand the policies in the Student Handbook. I agree to comply with all contract items listed above. Student Signature: Parent/Guardian Signature: Date: Date: Student s Name: Student s Home Phone: 3

Early Learning Services 1500 Highway 36 West Roseville, MN 55113-4266 REGISTRATION FORM FOR EARLY CHILDHOOD SCREENING ED-02390-06 (2012-2013 school year only) GENERAL INFORMATION AND INSTRUCTIONS: The front side (page one) of the registration form must be completed by the parent/guardian of the child. The back side (page two) is completed by school district personnel only. 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 Date Address Gender Male Female City State Zip Code Race/Ethnicity (mark ONLY one box) 1 - American Indian 3 - Hispanic 5 - White, not of Hispanic Origin 2 - Asian or Pacific Islander 4 - Black, not of Hispanic Origin Additional federal Race/Ethnicity categories are required for the 2012-2013 school year. Mark the box YES or NO in part A below. More than one box may be marked in B. *Part A Is the child Hispanic/Latino? (choose only one) NO, not Hispanic/Latino YES, Hispanic/Latino *Part B What is the child s race? American Indian/Alaska Native Asian Black/African American Native Hawaiian/Pacific Islander White 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 AND 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: Where: 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. Signature - Parent/Legal Guardian Date PAGE TWO TO BE COMPLETED BY SCHOOL DISTRICT PERSONNEL ONLY

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 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 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. iq Academy Minnesota 2. 3. Reason for request: (this does not affect your acceptance) 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 Contact Elaine Jahnke District Name Fergus Falls Title District Number ISD 544 Telephone Number (218)998-0544 x1010 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: iq Academy Minnesota Starting Date: 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 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 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. 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 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. 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

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 Mo/Day/Yr 2nd Dose Mo/Day/Yr 3rd Dose Mo/Day/Yr 4th Dose Mo/Day/Yr 5th Dose Mo/Day/Yr * 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 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. 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

2. Names of all Children in Household including Foster Children Attach additional page if necessary Application for Educational Benefits Free and Reduced-Price School Meals School Year 2012-13 State and Federally Funded Programs 1. Check here if this is the first application at this school district or nonpublic school for any child listed below. Date of Birth Month/Day/Year G r a d e School If Foster Child * Any Regular Income to Child Example: SSI Last Name First Name / / $ per / / $ per / / $ per / / $ per / / $ per * 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 your household, related or not. Attach additional page if necessary. Last Name First Name Check if NO Income 3. Benefits (if applicable) If any household member receives benefits from a program listed below: write in name of person and case number, check the appropriate box, and skip section 4. Name Case Number Minnesota Family Investment Program (MFIP) Supplemental Nutrition Assistance Program SNAP) Food Distribution Program on Indian Reservations (FDPIR) - Medical Assistance and WIC do not qualify 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 5. If your children are approved for school meal benefits, this information may be shared with Minnesota Health Care Programs to identify children who are eligible for Minnesota health insurance programs. Leave the box blank to allow sharing of information. See back page for more information. Do not share information with Minnesota Health Care Programs. Any Other Income, including net Farm/ Self-Employment $ per $ per $ per $ per $ per $ per $ per $ per $ per $ per $ per $ per $ per $ per $ per 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

Total Household Size: Total Incomes: $ per Approved (check all that apply): Case Number - Free Foster - Free Income Free Income Reduced-Price Office Use Only Signature Confirming Official: Date: Date Verification Sent: Response Due: 2 nd Notice: Denied: Incomplete Income Too High Other: Signature - Determining Official: Date: Result: No Change Free to Reduced-Price Free to Paid Only Reduced-Price to Free Reduced-Price to Paid Office Use Change Status To: Reason: Withdrawn: Reason for Change: Income Case number not verified Foster not verified Refused Cooperation Other: Signature Verifying Official: Date: Address: City Zip Home Phone: Work Phone: