Virginia Virtual Academy - A program of the Carroll County School District Enrollment Processing Center 2300 Corporate Park

Drive Suite 200 Herndon, VA 20171 Ph. 1.877.382.6514 Fx. 1.877.843.5902 www.k12.com/vava

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): 1-877-843-5902 Scan and Email: vavafax@k12.com Mail: Virginia Virtual Academy 2300 Corporate Park Drive Suite 200 Herndon, VA 20171
Provided by? Provided by you Provided by you Provided in this packet Provided in this packet Provided in this packet Provided in this packet Provided in packet Provided in this packet

Required For?

Item Proof of Age Proof of Residency

Description Official Birth Certificate (not the hospital issued certificate) Drivers License, Utility bill showing current address OR Mortgage Statement/ Rental contract including signature page.

Part 1. This section is filled out by the Parent/Guardian. Part 2. This form is Hearing, Vision and completed by your students physician. Part 3. This form is completed by your Immunization students physician. Notification of Offense Form Required for all Students Family Income Form Home Language Survey School Ethnicity Survey Release of Records Required for all students residing outside of the Carroll County School District Please complete and submit. Please complete and submit. Please complete and submit. Please complete and submit. By filling out this form, you are giving our school permission to request your students official records from their previous school after the approval process. If your child is enrolling in Kindergarten or was Homeschooled please indicate it on the form, fill out the top portion and sign it.

Application for Admission as a Non-Resident

Please complete and submit.

Provided in this packet

Required for IEP student with an IEP or other Special Evaluation Report Education needs Required for students that have a 504 plan 504 Accommodation Plan

A copy of your students 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 students ER, you can request a copy from your students current school. A copy of your students current 504 Accommodation Plan. Because the 504 expires yearly, please submit the current 504.

Provided by you Provided by you Provided by you

COMMONWEALTH OF VIRGINIA SCHOOL ENTRANCE HEALTH FORM Health Information Form/Comprehensive Physical Examination Report/Certification of Immunization
Part I HEALTH INFORMATION FORM
State law (Ref. Code of Virginia 22.1-270) requires that your child is immunized and receives a comprehensive physical examination before entering public kindergarten or elementary school. The parent or guardian completes this page (Part I) of the form. The Medical Provider completes Part II and Part III of the form. This form must be completed no longer than one year before your childs entry into school.

Name of School: ____________________________________________________________________________________ Current Grade: _________ ______________ Students Name: _________________________________________________________________________________________________________________________ Last First Middle Students Date of Birth: _____/_____/_______ Sex: _______ State or Country of Birth: ________________________ Main Language Spoken: ______________ Students Address: ______________________________________________________ City: ____________________ State: _______________ Zip: _______________ Name of Mother or Legal Guardian: ______________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______ Name of Father or Legal Guardian: ______________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______ Emergency Contact: __________________________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______

Condition Allergies (food, insects, drugs, latex) Allergies (seasonal) Asthma or breathing problems Attention-Deficit/Hyperactivity Disorder Behavioral problems Developmental problems Bladder problem Bleeding problem Bowel problem Cerebral Palsy Cystic fibrosis Dental problems

Yes

Comments

Condition Diabetes Head injury, concussions Hearing problems or deafness Heart problems Lead poisoning Muscle problems Seizures Sickle Cell Disease (not trait Speech problems Spinal injury Surgery Vision problems

Yes

Comments

Describe any other important health-related information about your child (for example, feeding tube, hospitalizations, oxygen support, hearing aid, etc.): _____________________________________________________________________________________________________________________________ __________ _______________________________________________________________________________________________________________________________ ________ List all prescription, over-the-counter, and herbal medications your child takes regularly: _______________________________________________________________________________________________________________________________________ Check here if you want to discuss confidential information with the school nurse or other school authority. Please provide the following information: Name Pediatrician/primary care provider Specialist Dentist Case Worker (if applicable) Childs Health Insurance: ____ None ____ FAMIS Plus (Medicaid) _____ FAMIS _____ Private/Commercial/Employer sponsored Phone Date of Last Appointment Yes No

I, ______________________________________ (do___) (do not___) authorize my childs health care provider and designated provider of health care in the school setting to discuss my childs health concerns and/or exchange information pertaining to this form. This authorization will be in place until or unless you withdraw it. You may withdraw your authorization at any time by contacting your childs school. When information is released from your childs record, documentation of the disclosure is maintained in your childs health or scholastic record. Signature of Parent or Legal Guardian: ______________________________________________________________________Date: _______/________/ _ _________

Signature of person completing this form: ____________________________________________________________________Date:_______/________/___________ Signature of Interpreter: __________________________________________________________________________________Date: ______ /_____/_______ MCH 213 G revised 10/2010

COMMONWEALTH OF VIRGINIA SCHOOL ENTRANCE HEALTH FORM Part II - Certification of Immunization

Section I To be completed by a physician or his designee, registered nurse, or health department official. See Section II for conditional enrollment and exemptions. A copy of the immunization record signed or stamped by a physician or designee, registered nurse, or health department official indicating the dates of administration including month, day, and year of the required vaccines shall be acceptable in lieu of recording these dates on this form as long as the record is attached to this form. Only vaccines marked with an asterisk are currently required for school entry. Form must be signed and dated by the Medical Provider or Health Department Official in the appropriate box.
Students Name:
Last First Middle

Date of Birth: |____|____|____| Mo. Day Yr.

IMMUNIZATION *Diphtheria, Tetanus, Pertussis (DTP, DTaP) *Diphtheria, Tetanus (DT) or Td (given after 7 years of age) *Tdap booster (6th grade entry) *Poliomyelitis (IPV, OPV) *Haemophilus influenzae Type b (Hib conjugate) *only for children <60 months of age *Pneumococcal (PCV conjugate) *only for children <2 years of age Measles, Mumps, Rubella (MMR vaccine) *Measles (Rubeola) *Rubella *Mumps *Hepatitis B Vaccine (HBV) Merck adult formulation used *Varicella Vaccine Hepatitis A Vaccine Meningococcal Vaccine Human Papillomavirus Vaccine Other Other Other 1 1 1 1 1

RECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN 2 2 3 3 4 4 5 5

2 2

3 3

4 4

1 1 1 1 1 1 1 1 1 1 1 1 1

2 2 2

Serological Confirmation of Measles Immunity: Serological Confirmation of Rubella Immunity:

2 2 2 2 3 Date of Varicella Disease OR Serological Confirmation of Varicella Immunity:

2 2 2 2

3 3 3 3 4 4 4 5 5 5

I certify that this child is ADEQUATELY OR AGE APPROPRIATELY IMMUNIZED in accordance with the MINIMUM requirements for attending school, child * Required vaccine care or preschool prescribed by the State Board of Healths Regulations for the Immunization of School Children (Minimum requirements are listed in Section III). Signature of Medical Provider or Health Department Official: Certification of Immunization 11/06 Date (Mo., Day, Yr.):___/___/____

MCH 213 G revised 10/2010

Students Name:

Date of Birth: |____ |_ ___|___ _|

Section II Conditional Enrollment and Exemptions

Complete the medical exemption or conditional enrollment section as appropriate to include signature and date.
MEDICAL EXEMPTION: As specified in the Code of Virginia 22.1-271.2, C (ii), I certify that administration of the vaccine(s) designated below would be detrimental to this students health. The vaccine(s) is (are) specifically contraindicated because (please specify): __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________. DTP/DTaP/Tdap:[ ]; DT/Td:[ ]; OPV/IPV:[ ]; Hib:[ ]; Pneum:[ ]; Measles:[ ]; Rubella:[ ]; Mumps:[ ]; HBV:[ ]; Varicella:[ ]

This contraindication is permanent: [

], or temporary [

] and expected to preclude immunizations until: Date (Mo., Day, Yr.): |___|___|___|. Date (Mo., Day, Yr.):|___|___|___|

Signature of Medical Provider or Health Department Official:

RELIGIOUS EXEMPTION: The Code of Virginia allows a child an exemption from receiving immunizations required for school attendance if the student or the students parent/guardian submits an affidavit to the schools admitting official stating that the administration of immunizing agents conflicts with the students religious tenets or practices. Any student entering school must submit this affidavit on a CERTIFICATE OF RELIGIOUS EXEMPTION (Form CRE-1), which may be obtained at any local health department, school division superintendents office or local department of social services. Ref. Code of Virginia 22.1-271.2, C (i).

CONDITIONAL ENROLLMENT: As specified in the Code of Virginia 22.1-271.2, B, I certify that this child has received at least one dose of each of the vaccines required by the State Board of Health for attending school and that this child has a plan for the completion of his/her requirements within the next 90 calendar days. Next immunization due on __________________. Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.):|___|___|___|

Section III Requirements

For Minimum Immunization Requirements for Entry into School and Day Care, consult the Division of Immunization web site at

http://www.vdh.virginia.gov/epidemiology/immunization

Children shall be immunized in accordance with the Immunization Schedule developed and published by the Centers for Disease Control (CDC), Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP), otherwise known as ACIP recommendations (Ref. Code of Virginia 32.1-46(a)). (requirements are subject to change.)

Certification of Immunization 10/2010

MCH 213 G revised 10/2010

Part III -- COMPREHENSIVE PHYSICAL EXAMINATION REPORT

A qualified licensed physician, nurse practitioner, or physician assistant must complete Part III. The exam must be done no longer than one year before entry into kindergarten or elementary school (Ref. Code of Virginia 22.1-270). Instructions for completing this form can be found at www.vahealth.org/schoolhealth Students Name: _______________________________________________ Date of Birth: _____/_____/__________ Sex: M F Physical Examination Date of Assessment: _____/_____/_______ 1 = Within normal 2 = Abnormal finding 3 = Referred for evaluation or treatment Weight: ________lbs. Height: _______ ft. ______ in. 1 2 3 1 2 3 1 2 3 Body Mass Index (BMI): ___________ BP____________ HEENT Neurological Skin Age / gender appropriate history completed Lungs Abdomen Genital Anticipatory guidance provided Heart Extremities Urinary TB Risk Assessment: No Risk Positive/Referred Mantoux results: __________________mm EPSDT Screens Required for Head Start include specific results and date: Blood Lead:___________________________________________ Hct/Hgb ____________________________________________

Health Assessment

Developmental Screen

Assessed for: Emotional/Social Problem Solving Language/Communication Fine Motor Skills Gross Motor Skills

Assessment Method:

Within normal

Concern identified:

Referred for Evaluation

Screened at 20dB: Indicate Pass (P) or Refer (R) in each box.

Hearing Screen

1000 R L

2000

4000

Referred to Audiologist/ENT Hearing aid or other assistive device

Unable to test needs rescreen

___Left ___Right

Permanent Hearing Loss Previously identified: Refer

Screened by OAE (Otoacoustic Emissions): Pass With Corrective Lenses (check if yes) Stereopsis Pass Fail Distance Both R 20/ 20/ Pass

Vision Screen

L 20/

Dental Screen

Not tested Test used:

Problem Identified: Referred for treatment No Problem: Referred for prevention No Referral: Already receiving dental care

Referred to eye doctor

Unable to test needs rescreen

Recommendations to (Pre) School , Child Care, or Early

Summary of Findings (check one): Well child; no conditions identified of concern to school program activities Conditions identified that are important to schooling or physical activity (complete sections below and/or explain here): _______________________ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ Intervention Personnel _____________________________________________________________________________________________________________________________ ___ Allergy food: _____________________ insect: _____________________ medicine: _____________________ other: _________________ Type of allergic reaction: anaphylaxis local reaction Response required: none epi pen other: _______________________________ ___Individualized Health Care Plan needed (e.g., asthma, diabetes, seizure disorder, severe allergy, etc) ___ Restricted Activity Specify: ______________________________________________________________________________________________ ___ ___ Developmental Evaluation

Has IEP Further evaluation needed for: ___________________________________________________________ Medication must be given and/or available at school.

___ Medication. Child takes medicine for specific health condition(s).

___ Special Diet Specify: ______________________________________________________________________________________________________ ___ Special Needs Specify: ____________________________________________________________________________________________________ __ Other Comments: _____________________________________________________________________________________________________________

Health Care Professionals Certification (Write legibly or stamp):

Name : _____________________________________ Practice/Clinic Name: __________________________________________ Phone: _______-_______-____________________ Signature: ________________________________________ Date: ____/_____/______ Address: ____________________________________________________________

Fax: _______-_______-_____________________ Email: _________________________________________

MCH 213 G revised 10/2010

Virginia Virtual Academy - A program of the Carroll County School District Enrollment Processing Center 2300 Corporate Park Drive Suite 200 Herndon, VA 20171 Ph. 1.866.654.8297 Fx. 1.877.843.5902 www.k12.com/vava

Notification of Offense Form

Parental Registration Statement: Student Name: Date of Birth: Please choose one of the following options and sign: Grade:

1. I, __________________________, affirm that my student, _________________________, was NOT previously suspended or expelled from any public or private school of this Commonwealth or any other State for an act or offense involving weapons, alcohol or drugs, or for the willful infliction of injury to another person or any act of violence committed on school property. OR 2. I, __________________________, affirm that my student, _________________________, WAS previously suspended or expelled from any public or private school of this Commonwealth or any other State for an act or offense involving weapons, alcohol or drugs, or for the willful infliction of injury to another person or any act of violence committed on school property. My student was suspended or expelled from the following school(s): My student was (check one of the following) o suspended or o expelled from the following school(s): School Name: ______________________________________________________________ Address: __________________________________________________________________ Telephone Number: _________________________________________________________ Expulsion/Suspension Start Date_________________ Expulsion/Suspension End Date__________________ My student was suspended or expelled for the following reason(s): (Please check all that apply)
o offense involving weapons o offense involving alcohol o offense involving drugs o willful infliction of injury to another person o an act of violence committed on school property o other (please note below)

Additional comments: _________________________________________________________ Signature ______________________________________________Date _______________

Students Name:

Students Home Phone:

201 -201 HOUSEHOLD APPLICATION FOR FREE AND REDUCED PRICE BREAKFAST AND LUNCH
COMPLETE ONE APPLICATION PER HOUSEHOLD Complete, sign, and return the application to any school in the division. Please read the instructions. Call 728-3191 OR 236-8145 if you need help completing this form.
Part 1.

List Names of all Household Members If applying for a foster child, Complete Parts 3,4,5,6 & 7 If applying for a homeless, migrant or runaway child Complete Parts 1,2,4,5,6 & 7
Last 1. 2. 3. 4. 5. 6. 7. Part 2. If the child you are applying for is Homeless Migrant or a First Middle Age Name of School Child Attends List SNAP/ Food Stamp or TANF Case #

List Gross Income (before any deductions) in whole dollars. Write in how often income is received, For Example: (W)= Weekly (2W)= Every 2 weeks (2M)= Twice a Month (M)= Monthly (Y)= Yearly
Earnings from Work Before Deductions, Wages, Salaries, and Tips or Strike Benefits, Unemployment Benefits, Workers Compensation or Earnings from Self-owned Business

Job 1
$ Amt./How Often $ $ $ $ $ $ $ / / / / / / /

Job 2
$ Amt./How Often $ $ $ $ $ $ $ / / / / / / /

Welfare, Child Support, Alimony

$ Amt./How Often $ $ $ $ $ $ $ / / / / / / /

Pensions, Retirement, Social Security

$ Amt./How Often $ $ $ $ $ $ $ / / / / / / /

Any Other Income

Check If No Income

$ Amt./How Often $ $ $ $ $ $ $ / / / / / / /

Runaway, check the appropriate box and call 728-3191 or 236-8145 to talk with the homeless liaison or migrant coordinator. Complete Parts 1 ,2, 4, 5, 6, and 7.

Part 3. If this is a FOSTER CHILD who is the legal responsibility of the courts check here . Also Complete Parts 4, 5, 6 & 7. Last First Middle Age Name of School Child Attends Grade Childs Monthly Income. Write 0 if the child has no personal use income.

Part 4. RACIAL IDENTITIES: You are not required to answer this question. If you choose to do so: Please mark one or more of the following racial identities: American Indian/Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other ETHNIC IDENTITIES: Please mark one of the following: Hispanic or Latino Not Hispanic or Latino Part 5. OTHER BENEFITS: Medicaid & Health Insurance: Your child may be eligible for other benefits. The school is allowed to share the information on this application with Medicaid and the Virginia children's health insurance program called FAMIS. If you do not want this information shared you must tell us by checking the NO block below. Your decision will not affect your child's eligibility for free or reduced price meals. NO, I do not want school officials to share information from my free or reduced price meal application with Medicaid or FAMIS. Part 6. MAILING ADDRESS AND PHONE: Write in your current address and phone number whre you may be reached in case of questions about your application

MAILING ADDRESS:________________________________________________________________

HOME PHONE: __________________ WORK PHONE: __________________

___________________________________________________________________________________________________________________________________________________________________________ Part 7. SIGNATURE & SOCIAL SECURITY NUMBER: An adult household member must sign the application and provide a social security # before it can be approved. (See Privacy Act Statement on back)
PENALTIES FOR MISREPRESENTATION: I certify that all of the above information is true and correct and that the SNAP/food stamp/TANF number is correct or that all income is reported. I understand that this information is being given for the receipt of Federal funds; that institutional officials may verify the information on the statement and that the deliberate misrepresentation of the information may subject me to prosecution under applicable State and Federal laws.

I Do Not Have A Social Security Number

Social Security Number of Adult Signing Application

SIGN HERE
Signature of Adult Household Member
Free Reduced

___________________ Date

Date Selected: Response Due: 2nd Notice: Results Sent:

VERFICATION SUMMARY No Change Reason F to R Income F to Pd Household Size R to F R to Pd Refused to Cooperate Change in SNAP/FS/TANF

DO NOT WRITE BELOW LINE SCHOOL USE ONLY TOTAL INCOME / HOW OFTEN / HOUSEHOLD SIZE: $ / /

STATUS
SNAP/Food Stamps/TANF Foster Child

Temporary Free Date Approval/Denial Notice Sent: Denied Signature of Approving Official:

Expires: Income Incomplete Application

Verifying Officials Signature

INSTRUCTIONS FOR COMPLETING THE HOUSEHOLD APPLICATION FOR FREE AND REDUCED PRICE BREAKFAST AND LUNCH To apply for free or reduced price breakfast and lunch, complete one application for ALL children in the household who are in school using the following instructions. Sign the application. An application cannot be processed without it. Return the application to any school in the school division. Call 728-3191 or 236-8145 if you need help. If your household receives SNAP/Food Stamp/VA TANF, follow these instructions to complete:
PART 1: PART 4: PART 5 PART 6 PART 7 List each Childs Complete Name, Age, School, and SNAP/Food Stamp/TANF case number. This number is in your approval letter. If you list a SNAP/ Food Stamp/TANF number, you do not need to list names of other household members or income. Complete the racial/ethnic identity question if you wish. You are not required to answer this question to get meal benefits. We need this information to make sure that everyone is treated fairly. Your child may be eligible for other benefits. To obtain meal benefits, you are not required to complete this section. Read part 5 of the application. Print your complete address and phone number where you may be reached in case of a question about your application. SIGN HERE. The application must have the signature of an adult household member. No social security number is needed if a SNAP/Food Stamp/TANF case number is provided.

If you are applying for a FOSTER CHILD, follow these instructions to complete:
PART 3: Use a separate application for each foster child. A foster child is the legal responsibility of a welfare agency or court. List Childs Complete Name, Age, School Child Attends, Grade and the Childs Monthly personal use income. Write 0 if the foster child does not get personal use income. Personal use income is (a) money given by the welfare office identified by category for the childs personal use, such as for clothing, school fees, and allowances; and (b) all other money the child gets, such as money from his/her family and money from the childs full time or regular part time jobs. Complete the racial/ethnic identity question if you wish. You are not required to answer this question to get meal benefits. We need this information to make sure that everyone is treated fairly. Your child may be eligible for other benefits. To obtain meal benefits, you are not required to complete this section. Read part 5 of the application. Print your complete address and phone number where you may be reached in case of a question about your application. SIGN HERE. The application must have the signature of foster parent or other official representing the child. No Social Security Number is needed.

PART 4: PART 5: PART 6: PART 7:

ALL OTHER HOUSEHOLDS (including WIC) without a SNAP/Food Stamp/TANF number, follow these instructions to complete:
PART 1: - Write the names of everyone in your household, whether they get income or not. Include yourself, all children who are in school, all other children, your spouse, grandparents, and other related and unrelated people in your household. Use another piece of paper if you need more space. - Write the amount of income each household member got last month, before taxes or anything else is taken out, and how often it was received. For example, list the gross income each person earned from work. The amount should be listed on your pay stub. This is not the same as take home pay; it is the amount before taxes and other deductions. Next to the amount write how often the person received it. If any amount last month was more or less than usual, write that person's usual income. (See Example Below) Check category, if applicable, and contact the homeless liaison or migrant coordinator at 728-3191 or 236-8145. Complete parts 4,5,6, & 7. Complete the racial/ethnic identity question if you wish. You are not required to answer this question to get meal benefits. We need this information to make sure that everyone is treated fairly. Your child may be eligible for other benefits. To obtain meal benefits, you are not required to complete this section. Read part 5 of the application. Print your complete address and phone number where you may be reached in case of a question about your application. SOCIAL SECURITY NUMBER AND SIGNATURE. The application must have the social security number and signature of an adult household member. The application must have the social security number of the adult who signs. If the adult who signs does not have a social security number, they must check the box I Do Not Have A Social Security Number.

PART 2: PART 4: PART 5 PART 6: PART 7:

TYPES OF INCOME TO REPORT AND HOW TO REPORT THEM ON THE APPLICATION

Names of ALL Household Members If applying for a foster child, Complete Part 3,4,5,6 & 7 If applying for a homless, migrant or runaway child, Complete Parts 1,2,4,5, 6 & 7 Age Name of School Child Attends Food Stamp or TANF Case # Earnings from Work Before Deductions, Wages, Salaries, Tips, Strike Benefits, Unemployment Compensation, Workers Compensation, Net Income from Self-Owned Business or Farm
Job 1 Amount/How Often Job 2 Amount/How Often

Welfare/Child Support/ Alimony Public Assistance Payments, Welfare Payments, Alimony/Child Support Payments

Pensions/Retirement/ Social Security Pensions, Supplemental Security Income, Retirement Income, Veterans Payments, Social Security

(Example) Jane Smith $200/ Week $100/ Week $150/ Month $100/ Month 42  (Example) Sue Smith AB Elem 10 Privacy Act Statement: Unless you list the childs SNAP/food stamp, or TANF case number, Section 9 of the National School Lunch Act requires that you include the social security number of the household member signing the application or indicate that the household member does not have a social security number. You do not have to list a social security number, but if a social security number is not listed or an indication is not made that the adult household member signing the application does not have a social security number, we cannot approve the application. The social security number may be used to identify the household member in verifying the correctness of information stated on the application. This may include program reviews, audits, and investigations and may include contacting employers to determine income, contacting a SNAP/food stamp or TANF office to determine current certification for SNAP/food stamps, or TANF benefits, contacting the State employment security office to determine the amount of benefits received and checking the documentation produced by the household member to prove the amount of income received. These efforts may result in a loss or reduction of benefits, administrative claims, or legal actions if incorrect information is reported. The social security number may also be disclosed to programs as authorized under the National School Lunch Act and Child Nutrition Act, the Comptroller General of the U.S., Law enforcement officials for the purpose of investigating violations of certain federal and state laws, and local education, health, and nutrition programs.

Other Income Disability Benefits, Cash Withdrawn from Savings, Interest/ Dividends, Income from Estates/Trusts/ Investments, Regular contributions from persons not living in the household, Net Royalties/ Annuities/ Net Rental Income, Any Other Income $50/ 2Month

Check If No Income

Non-discrimination Statement: 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 Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (800) 795-3272 or (202) 720-6382 (TTY). USDA is an equal opportunity provider and employer.

Carroll County Public Schools Student Home Language Survey

Students Name: __________________________________________ Date: _____________________________

Grade: _____________

Teacher: __________________________

School: _____________________________

Relationship of Person Completing Survey: Mother Father Guardian Other (specify): _______________________________

Check the best answer to each question:

1. Was the first language learned by the student English? 2. Can the student speak languages other than English?

Yes Yes

No No

Which other languages? __________________________________________ 3. Which language does the student use most often when speaking to friends? English Other language: ___________________________

4. Which language does the student use most often when speaking to his/her parents? English Other language: ___________________________

5. Does anyone in your home speak a language other than English?

Yes

No

Which other language? ___________________________________________

6. Have you moved in order to obtain agriculture work in the past 36 months?

Yes

No

7. In what country was the student born? ___________________________________

8. Is the student:

US Citizen

Immigrant

Refugee
_____________________________________ Date

_________________________________________________ Parent Name Print

_________________________________________________ Parent or Guardian Signature

_____________________________________ Date

Office use only: o If the answer to Number 2 is yes, and other languages are given as answers to numbers 3, 4, or 5, the students English abilities should be tested even if the students oral ability is good. In this case, a copy of this form should be given to the schools ESL teacher and the divisions ESL coordinator. o One copy of this form should be kept in the students permanent record.

Carroll County Public Schools Ethnicity Survey

Please Print

Students Last Name

Students First Name Students Middle Name Students Current Grade Students Current School

Part A and Part B must be completed

Part A.

Is this student Hispanic/Latino? (Choose only one) No, Not Hispanic/Latino Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American,
or other Spanish culture or origin, regardless of race.) The above part of the question is about ethnicity, not race. No matter what you selected above, please continue to answer the following by marking one or more boxes to indicate what you consider your students race to be.

Part B.

What is the students race? (Choose one or more) American Indian or Alaska Native (A person having origins in any of the original peoples of
North and South America (including Central America), and who maintains tribal affiliation or community attachment.)

Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or
Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippne Islands, Thailand, and Vietnam.)

Black or African American (A person having origins in any of the black racial groups of Africa) Native Hawaiian or Other Pacific Islander (A person having origins in any of the original
peoples of Hawaii, Guam, Samoa, or other Pacific Isalnds.)

White (A person having origins in any of the original peoples of Europe, the Middle East, or
North Africa.)

Virginia Virtual Academy - A program of the Carroll County School District Enrollment Processing Center 2300 Corporate Park Drive Suite 200 Herndon, VA 20171 Ph. 1.866.654.8297 Fx. 1.877.843.5902 www.k12.com/vava

Release of Student Records

Student Information
Students Full Name:
first middle last

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).

Students Date of Birth: Students Legal Address:

Students Social Security Number:

street

apt #

city

county

state

zip

Home Phone:

Homeschooled or Never Previously Enrolled in School (Fill out only if applicable)

Check below if applicable: o Student was always previously homeschooled o Student is enrolling in Kindergarten

Prior School Information

Name of Prior School: Schools Address:

street

city

county

state

zip

Schools Phone:

Schools Fax:

Sign and Date below

Name of Parent or Legal Guardian: Parent/Guardians Signature:
first last

Date:

SCHOOL OFFICIALS ONLY: Send student records to: Virginia Virtual Academy Enrollment Processing Center 2300 Corporate Park Drive, Suite 200 Herndon, VA 20171

Students Name:

Students Home Phone:

CARROLL COUNTY PUBLIC SCHOOLS 605-9 PINE STREET HILLSVILLE, VIRGINIA 24343 (276) 728-3191 (276) 236-8145

APPLICATION FOR ADMISSION AS A NON-RESIDENT STUDENT

For School Year ________________ Students Name _________________________________________________________________ LAST FIRST MIDDLE Date of Birth _______________________________ MONTH DAY YEAR Age ______ Male ____ Female ____

Name of Parent(s) or Legal Guardian(s) __________________________________________________ Current Legal Address (911) ___________________________________________________________ Mailing Address ____________________________________________________________________ Home Telephone ____________________ Work Telephone _____________ Cell ________________ County or City of Residence ___________________ Name, Address, and Telephone Number of School Last Attended By Student: _____________________________________________________________ _____________________________________________________________ ____________________________________________________________ Reason for Leaving Previous School: __________________________________________________________________________________ If the Student Has Been Enrolled in Any Special Education Programs in the School(s) Last Attended, Please Specify: ______________________________________________________________________ School Requesting to Attend: __________________________________ Grade: _________________ Why Do You Wish to Enroll Your Child in Carroll County Public Schools? __________________________________________________________________________________ I certify that the information in this application is true and accurate to the best of my knowledge and that I have been provided, read, understood, and signed the Student School Assignment Guidelines. ____________________ Date _______________________________________ Signature of Parent/Guardian

I affirm that the above name student has not been suspended or expelled from school attendance at a private or public school nor has been assigned to any correctional facility or placed on probation by the court system. ____________________ Date _______________________________________ Signature of Parent/Guardian (OVER)

CARROLL COUNTY PUBLIC SCHOOLS STUDENT SCHOOL ASSIGNMENTS NON-RESIDENT STUDENT REQUESTS Consideration of a request to register a non-resident student from another school division in Virginia is contingent upon the following: 1. Completion of an APPLICATION FOR ADMISSION AS A NON-RESIDENT STUDENT. Applications must be returned to the Office of the Division Superintendent. 2. Availability of space in the grade level and/or program which is indicated by current placement. Acceptance and/or continued enrollment of a non-resident student will not require the initiation of a new program, the employment of additional personnel, the alteration of existing facilities, or the payment of special services beyond those provided in the Carroll County Public Schools. The approval of a non-resident student application will be subject to maintaining available space in a grade level/program for students who may move into the attendance area. 3. Continued enrollment of a non-resident student is subject to annual review. All non-resident student applications will be subject to renewal on an annual basis. Continuation applications must be received in the Office of the Superintendent within the designated timeline otherwise the application will be processed as a new request. Continued placement in a Carroll County School by a non-resident student will be contingent upon available space, programs, discipline, and school attendance. Students are subject to all policies, regulations, and guidelines of the school division and the Carroll County Public Schools Student Handbook. Notification of approval will be on an annual basis. 4. The superintendent will approve or deny non-resident student applications based upon a review of the application, recommendation by school principal or others as necessary, and the availability of space and/or programs. 5. Approval of non-resident student status may be revoked. Non-resident students would be expected to return to the school division in which they reside when their enrollment creates any of the conditions described above in numbers two and three. Transfer to another school in Carroll County is subject to the same approval process. 6. Transportation of non-resident students is the responsibility of the parent or guardian. Non-resident transfer students may board a bus at a bus stop that serves the school they have been approved to attend. 7. Any transfer request that is received and/or approved based upon false or misleading information will be declared void and the transfer will be rescinded. 8. The superintendent reserves the right to remove the privilege to attend Carroll County Public Schools. 9. Failure to meet any of the above criteria will result in an immediate removal from Carroll County Public Schools. _____________________ DATE ___________________________________ Signature Parent or Guardian

OUT OF STATE STUDENT REQUESTS Consideration of a request to register a non-resident student from another state is contingent upon the following: 1. 2. 3. All criteria set forth in aforementioned non-resident guidelines of student school assignments. Payment of any applicable tuition charges prior to enrollment. If, for any reason, the parent does not remit tuition within the prescribed time limit, the approval for transfer may be rescinded. If payment is not made, determination for future enrollment as a transfer student will be denied. ___________________________________ Signature Parent or Guardian ADOPTED: 08/04/93 03/29/05 10/10/06

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