Documentation Required for Application. Documentación Requerida para Aplicación
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1 Parent/Guardian Copy Documentation Required for Application Copy of Student Birth Certificate Proof of Immunization Proof of Residence / Utility Bill Parent Registration Statement Home Language Survey Completed Student Application Check off upon receipt Documentación Requerida para Aplicación Confirmación de Documento Recibido Copia del acta de nacimiento del estudiante Pruebas de Inmunización (Vacunas) Prueba de Residencia/Factura de Servicios Declaración del Padre Acerca del Registro Disciplinario Encuesta de Idioma Usado En el Hogar Aplicación del estudiante-año
2 K-12 Student Application Grade Applying Please print: Student s Full Name: Last First Middle Initial Mailing Address: (proof of residency is required upon acceptance) Street City or Town State Zip Code Date of Birth: Current Grade Current School: Sibling Information: Please indicate below any sibling/s currently attending Esperanza Cyber Charter School. Last Name First Name Current Grade Last Name First Name Current Grade PARENTS/GUARDIANS INFORMATION Parent/Guardian s Full Name: Last First Middle Initial Mailing Address: (If different than students) Street City or Town State Zip Code Cellular Number: Home Phone Number Work Phone Number: Address: Parent/Guardian Signature: Date: Parent Confirmation/Receipt K-12 th Date Received: Time Received: Staff Initials: Orientation Date (if application is complete) Parent/Guardian s Name: Student s Name: Application may be completed onsite/online or returned via fax or mail to address listed below. 2
3 K-12 Aplicación del estudiante-año Grado Solicitando Favor escribir en letras de molde: Nombre del estudiante: Apellido Primer Nombre Inicial Dirección: (al aceptarle, prueba de residencia es requerida) Calle Ciudad o Pueblo Estado Código Postal Fecha de nacimiento: _ Grado actual: Escuela anterior: Información sobre hermanos: Por favor indique en las siguientes líneas el nombre de hermano/a que este actualmente asistiendo Esperanza Cyber Charter School. Apellido Primer Nombre Grado Actual Apellido Primer Nombre Grado Actual INFORMACIÓN DE PADRE/GUARDIÁN Nombre completo del Padre/Guardián: Apellido Primer Nombre Inicial Dirección: (si es diferente a la del estudiante) Calle _ Ciudad o Pueblo Estado Código Postal Número de teléfono Celular Número telefónico del hogar: Número de teléfono del empleo: Correo Electrónico: Firma de Padre/Guardián: Fecha: _ Confirmación/recibo del padre K-12 th Fecha Recibida: Hora Recibida: Iniciales del empleado escolar: Fecha de Orientacion (Si la aplicación esta completa) Nombre del Padre/Guardián: Nombre del estudiante, solicitando: La aplicación puede ser presentada personalmente/electrónicamente o a través de fax o correo 3
4 PARENT/GUARDIAN REGISTRATION STATEMENT (Required) Pennsylvania School Code A states in part Prior to admission to any school entity, the parent, guardian or other person having control or charge of a student shall, upon registration, provide a sworn statement or affirmation stating whether pupil was previously or is presently suspended or expelled from any public or private school of this Commonwealth or any other state for an act offense involving weapons, alcohol or drugs, or for the willful infliction of injury to another person, or for any act of violence committed on school property. Student Name Grade Date of Birth Parent/Guardian Name I hereby affirm that my child was or was not previously suspended or expelled from any public or private school of this Commonwealth or any other state for the act or offense involving weapons, alcohol or drugs, or for the willful infliction of injury to another person, or for any act of violence committed on school property. I make this statement subject to the penalties of 24 P.S A(b) and 18 Pa. C.S.A. 4904, relating to unsworn falsification to authorities, and the facts contain herein are true and correct to the best of my knowledge. Parent/Guardian Signature Date If your child, the student, has been or is presently suspended or expelled from another school, please complete the following: Name of school from which the student was suspended or expelled Date of suspension or expulsion Reason for suspension or expulsion Provide additional schools, dates, and reasons, if applicable Parent/Guardian Signature Date Any willful false statement made above shall be a misdemeanor of the third degree. This form shall be maintained as part of the student s disciplinary record. 4
5 PADRE/GUARDIAN DECLARACIÓN DE REGISTRO (Necesario) El Código Estudiantil de Pensilvania A establece que "Antes de la admisión a cualquier entidad escolar, el padre, guardián u otra persona que tenga autoridad o cargo de un estudiante deberá, antes de la inscripción, presentar una declaración jurada o afirmación indicando si el Estudiante ha sido suspendido con anterioridad o fue expulsado de una escuela pública o privada de esta comunidad o cualquier otro estado por un acto delictivo relacionado con armas, alcohol o drogas en la actualidad, o por infligir intencionalmente lesiones a otra persona o por cualquier acto de violencia cometido en propiedad de la escuela". Nombre del Estudiante: Grado: Fecha de Nacimiento: Nombre del Padre/Guardian: Por lo presente afirmo que mi hijo(a) fue o nunca fue suspendido o expulsado de una escuela pública o privada de esta comunidad o cualquier otro estado por el acto o delito relacionado con armas, alcohol o drogas anteriormente, o por infligir intencionalmente lesiones a otra persona, o por cualquier acto de violencia cometido en la propiedad de la escuela. Hago esta declaración sujeta a las sanciones de 24 P. S A (b) y 18 P.a. C.S.A. 4904, referentes a declaraciones falsas a las autoridades. Aseguro que la información que contiene este documento es verdadero y correcto a lo mejor de mi conocimiento. Firma del Padre/Guardian: Fecha: Si su hijo, el estudiante, ha sido o está actualmente suspendido o expulsado de otra escuela, por favor complete lo siguiente: Nombre de la escuela donde el Estudiante fue Fecha de la Razón de la suspensión o expulsión: Suspendido o Expulsado: Suspensión o Proporcionar escuelas adicionales, fechas y razones, si es necesario: Expulsión: Firma del Padre/Guardian: Fecha: Cualquier declaración intencionalmente falsa en esta aplicación será un delito de tercer grado. Esta forma se mantendrá como parte del expediente de disciplina del estudiante. 5
6 HOME LANGUAGE SURVEY ALL newly registering students regardless of race, nationality, or language of origin MUST complete this form. Federal law requires all Local Education Agencies (LEAs) utilize a non-biased procedure for identifying which students are potential English Learners (Els) to provide appropriate language instruction, educational programs, and services. Given this responsibility, LEAs have the right to ask for information contained on this and other forms associated with the identification process. Student s First Name: Student s Family Name: Student s Date of Birth (month/day/year) / / 1. Is a language other than English spoken in the home? Yes No If Yes, please list the language(s) 2. Does your child communicate in a language other than English? Yes No If Yes, please list the language(s) 3. What is the language your child first learned to speak? 4. When was your child first enrolled in a US school? (date) 5. Has the student attended any United States school in any 3 years during his/her lifetime? Yes No If Yes, to attended US Schools, please complete the following: Name of School 1 State Dates Attended Name of School 2 State Dates Attended Name of School 3 State Dates Attended 6. When did your child first enter a school in Pennsylvania? (date) Is the student currently enrolled in an English as a Second Language (ESL) program? Yes No Has the student been removed (exited) or promoted from ESL services? Yes No Person completing this form (if other than the parent/guardian) Parent/Guardian Signature If Yes, date of exit or promotion *The School district /charter school had the responsibility under the federal law to serve students who are English Learners and need English Language instructional services. Given this responsibility, the school district/charter school has the right to ask for the information it needs to identify English Learners. As part of the responsibility to locate and identify an ELs, the School may administer tests and ask for information about EL students who are enrolled in the school as well as students who are applying. Revised Date 6
7 ENCUESTA DEL IDIOMA USADO EN EL HOGAR Todos los estudiantes que se registren nuevamente independientemente de su raza, nacionalidad o idioma de origen deben completar este formulario. La ley federal requiere que todas las agencias de educación local (LEAs) utilicen un procedimiento no sesgado para identificar qué estudiantes que potencialmente son aprendices de inglés (Els) para proveer instrucción apropiada del idioma, programas educacionales y servicios. Dada esta responsabilidad, LEAs tiene el derecho de pedir información contenida en este y otros formularios asociados con el proceso de identificación. Nombre del estudiante: Nombre de familia (Apellido de estudiante) Fecha de Nacimiento (M/D/Año) / / 1. Se habla un idioma diferente al inglés en el hogar? Yes No En caso afirmativo, enumere el (los) idiomas(s) 2. Su hijo se comunica en un idioma diferente al inglés? Yes No En caso afirmativo, enumere el (los) idiomas(s) 3. Cuál es el idioma que su hijo aprendió primero a hablar? 4. Cuándo se inscribió por primera vez su hijo en una escuela de los EE. UU.? (fecha) 5. Ha asistido el estudiante a cualquier escuela de los Estados Unidos en 3 años durante su vida? Yes No En caso afirmativo, complete lo siguiente: Nombre de la escuela # 1: Ciudad/Estado: Fechas en que asistió: Nombre de la escuela # 2: Ciudad/Estado: Fechas en que asistió: Nombre de la escuela # 3: Ciudad/Estado: Fechas en que asistió: 6. Cuándo ingresó su hijo por primera vez en una escuela en Pensilvania? (fecha) Actualmente el estudiante está inscrito en un programa de Inglés como Segundo Idioma (ESL)? Sí No El estudiante se ha retirado o promovido de los servicios de ESL? Sí No Nombre de la Persona que completo este formulario (Si no es el Padre/Guardián legal): Firma del Padre/Guardián legal: En caso afirmativo, Fecha de salida o promoción: Fecha: El Centro Educativo tiene la responsabilidad bajo la ley federal, de atender a los estudiantes que tienen dominio limitado del inglés (Limited English Proficient-LEP) y necesitan servicios de instrucción en inglés. De acuerdo con esta responsabilidad, la escuela tiene derecho a solicitar la información que necesita para identificar a los estudiantes que tienen un dominio limitado del inglés (English Language Learners- ELLs). Como parte de la responsabilidad de ubicar e identificar a los ELL, la escuela puede realizar evaluaciones o pedir información relacionada con los estudiantes que ya estén inscritos en la escuela, así como de estudiantes que se inscriban en el futuro. 7
8 FOR OFFICE USE ONLY Required Enrollment Documents Staff Initials Document Comments Completed application Proof of Childs Age Proof of Immunization Status Proof of PA Residency Parent/Guardian Registration Statement Signed and dated Birth certificate; baptismal certificate; notarized statement from the parent indicating the date of birth; valid Passport; prior school indicating the date of birth All immunizations records must be up to date Deed, Lease, Utility bill, Vehicle Registration, PA Driver s License or Dept. of Transportation ID card Completed, Signed and dated Other Essential Documents Needed: Check when obtained and attach to application. Proof of Withdraw from Previous School Current Report Card, Progress Report, Transcript Discipline Record Student Service Reports Individualized Education Plan Evaluation or Re-evaluation Report NOREP 504 Plan ACCESS (ESL) PA State Exam Reports (PSSA, Keystone) Parent/Guardian Picture Identification Proof of Internet Service Provider Student Physical Exam Student Dental Exam Application Review: Sign Date Comments Front Office: I have reviewed application for all required documents (5) and have requested essential documents Registrar: I have reviewed application for information needed to register the child into the grade. Guidance: I have reviewed applicable documents for grade and course placement. ESL/Special Education: I have reviewed applicable documents for student services. STUDENT IS ENROLLED FOR THE FOLLOWING ORIENTATION DATE 8
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