OPEN-ENROLLMENT CHARTER CONTRACT RENEWAL APPLICATION. Section I. Current Information in Charter School Tracking System
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(2) Section II. Superintendent and Board Chair Contact Information The school superintendent and/or the charter holder board chair will be contacted by agency staff if there are issues to be resolved in any of the sections.. Superintendent Contact Information: /. Superintendent's Name:. Joyce Brown. Telephone Number:. 817496-3003. Fax Number:. 817496-3004. E-mail Address:. Joyce, [email protected]. / /. (/. Charter Holder Board Chair Contact Information: Charter Holder Board Chair's Name:. Robert Scarborough. Telephone Number:. 817-896-1289. / /. I Fax Number:. /. None. E-mail Address:. Intentionally Left Blank.
(3) Section III. Governance Structure and Procedures. Before completing the following items, please review TEC, §12.121 and 19 TAC §100.1Q33(c)(6)(C)(i) and also relevant portions of 19 TAC §§100.1101-100.1159; these laws and rules are available on the on-line resource page. A. In the table below, please fill in the information requested concerning the members of the governing body of the charter holder. Please note the following: •. The column concerning compensation requires the charter holder to report the total amount of annual compensation that each board member receives from the charter holder or charter school for any purpose (i.e., salary, contract work, etc.).. •. A "relative -within the third degree of consanguinity or affinity, " refers to a board member's spouse, or the board member's or his or her spouse's: parents, children, grandchildren, siblings, grandparents, great-grandparents, nieces, nephews, aunts, uncles, and great-grandchildren.. Charter Holder Board Member's Name. Office Held. Robert Allen Scarborough. Aya Nomura Blake Wayne Moorman. ^/. / ^/. ,/. Merrie Beth King Barbara Shipman. £/ */. Amount of Compensation, Per Year, Received from Charter. Holder or. Charter School. Relative(s) Within the Third Degree of Consanguinity or Affinity (see definition above) Also Serving on the Governing Body of Charter Holder. Yes/No. President. $0.00. No. Member. $0.00. No. Vice-Treasurer. $0,00. No. Member. $0.00. No. Secretary. $0.00. No. John Roberts. /. Treasurer. $0.00. No. Sandy Joyce. -/. Vice President. $0.00. No. Click Here. $. Click Here. $. Click Here. $. Click Here. $. i/. r*(/,' A. Pliflf Ht»r*>. Use the area above if additional space is needed.. Relation to Board Member (use the space provided below to list additional relatives).
(4) B. If any charter holder board member has a relative within the third degree of consanguinity or affinity (see definition in subsection A) who is receiving or will receive any compensation from the charter holder or the charter school for any purpose, please fill in the information requested in the table below. Charter Holder Board Member's Name. Relative's Name. Relative's Employment Position or Basis for Compensation. C. If the charter holder governing body has created a secondary governing body, commonly known as a "governing body of the charter school or "charter school board," to perform some of its duties with respect to the charter school, please fill in the information requested in the table below.. Charter School Board Member's Name. Office Held. Relative(s) Within the Third Degree of Consanguinity or Affinity ( see definition in subsection A) Also Serving on Governing Body of Charter School.
(5) D. If any charter school board member has a relative within the third degree of consanguinity or affinity (see definition in subsection A) who is receiving or will receive any compensation from the charter holder or charter school for any purpose, please fill in the information requested in the table below.. Charter School Board Member's Name. Relative's Name. Relative's Employment Position or Basis for Compensation. Use the box below if additional space is needed. E. If a separate governing body of the charter school exists, please describe the roles and responsibilities that the governing body of the charter holder has delegated to the governing body of the charter school. If there is only one governing body, no response is required. Type Below:. F. Submit as Attachment 1, the charter holder's organizational chart that illustrates all of the charter holder's operations, including the charter school's organizational structure; and as Attachment 2, a biographical affidavit for each member of the governing body of the charter holder and of the governing body of the charter school, if applicable. The biographical affidavit must be completed online, printed and notarized. The online version of the biographical affidavit is available on the on-line resource page..
(6) 9a. Attachment I. Q_. CD. •3 o. O. o. -8. O. Tl O. Q). m.
(7) Attachment II. East Fort Worth Montessori School, Incorporated. Biographical Affidavits. 9b.
(8) TEXAS EDUCATION AGENCY. RENEWAL APPLICANT. BIOGRAPHICAL AFFIDAVIT. (MUST COMPLETE ONLINE VERSION, PRINT, and NOTARIZE). Check all that apply: 0Member of the governing board of the charter holder QMember of the governing board of the charter school (if a separate secondary board exists) Full Name of Charter Holder: (i.e., nonprofit corporation, institution of higher education, or governmental entity). East Fort Worth Montessori School, Inc.. Full Name of Charter School:. East Fort Worth Montessori Academy. In connection with the above-named organization and charter school renewal application, I make. representations and supply information about myself as hereinafter set forth. (Attach addendum or. separate sheet if space hereon is insufficient to answer any questions fully.). IF ANSWER IS "NO" OR "NONE", SO STATE. 1. Full Name (Initials Not Acceptable):Blakc Wayne Moorman 2. Have you ever had your name changed or used another name? If yes, give reason for the change:. I |Y es. No. ___„. Maiden Name (if female): Other names used at any time: 3. If in addition to being a charter holder or charter school board member, you serve or are employed as an "officer of an open-enrollment charter school" as the term is defined in TEC § 12.1012(6), state your school officer position N/A. 4. If you expect to receive any compensation for any purpose from the charter holder, the charter school, or a management company of the charter school, provide the information requested below: Amount of annual compensation SO.00. Reason for compensation:. 5. Current Employer: City of Fort Worth. TX Occupation: Operations Manager. Fort Worth Convention Center 1.
(9) 6. List all previous experience with charter schools. Include open-enrollment schools and/or campus or program charters: DATES. CHARTER SCHOOL. ADDRESS. TITLE. 7. List all previous experience with any charter school management company: DATES. MANAGEMENT COMPANY. ADDRESS. TITLE. . Is any relative within the third degree of consanguinity (i.e., your parent, grandparent, greatgrandparent, child, grandchild, great-grandchild, sibling, aunt, uncle, niece, nephew) or within the third degree of affinity (i.e., your spouse or your spouse's parent, grandparent, great-grandparent, child, grandchild, great-grandchild, sibling, aunt, uncle, niece, nephew) also a member of the charter holder governing body or charter school governing body?. U Yes. HNo. If yes, give details:. 9. Will any relative(s) within the third degree of consanguinity or affinity (see definitions in Question 8 above) be employed by or receive any compensation or remuneration from the charter holder or the charter school?. DYes 0No. If yes, give details:.
(10) 10. Have you ever been convicted of a misdemeanor involving moral turpitude or any felony?. DYes 0NO. If yes, give details:. Dated and signed this 1 \thday ofMay 2007. I herby certify under penalty of perjury that I am acting on my own behalf, and that the foregoing statements are true and correct to the best of my knowledge and belief. (Signatu/e of Affiant). VERIFICATION. State of Texas. county of. tc^r rom f. .. VY^cforv-y\Air\(name of affiant) appeared before me the undersigned notary On this day,tj>lri.k P_ ljJc»4 public and deposed h aThe/sn a h e / s n e executed the above instrument and that the statements and answers contained therein are true and correct to the best of his/her knowledge and belief. Subscribed and sworn to before me this V/ // r fV; • ' • •'$&. •?-> • •• • • '.-";4fl;. :!":••- '. f. day of. kjJ. , 20 Q :J. :l '-$k. •^*^r. (Notary Public) (SEAL). My commission expires L,fU/H_l. /7. *L$& /.
(11) TEXAS EDUCATION AGENCY. RENEWAL APPLICANT. BIOGRAPHICAL AFFIDAVIT. (MUST COMPLETE ONLINE VERSION, PRINT, and NOTARIZE). Check all that apply: 0Member of the governing board of the charter holder QMember of the governing board of the charter school (if a separate secondary board exists) Full Name of Charter Holder: (i.e., nonprofit corporation, institution of higher education, or governmental entity). inc.. Full Name of Charter School:. East Fort worth Montessori School, East Fort worth Montessori Academy. In connection with the above-named organization and charter school renewal application, I make. representations and supply information about myself as hereinafter set forth. (Attach addendum or. separate sheet if space hereon is insufficient to answer any questions fully.). IF ANSWER IS "NO" OR "NONE", SO STATE. 1. Full Name (Initials Not Acceptable):Merrie Beth King 2. Have you ever had your name changed or used another name?. xYes. I JNo. If yes, give reason for the change: Marriage Maiden Name (if female): Montgomery Other names used at any time: Merrie Beth Montgomery de Suarez 3. If in addition to being a charter holder or charter school board member, you serve or are employed as an "officer of an open-enrollment charter school" as the term is defined in TEC § 12.1012(6), state your school officer position. 4. If you expect to receive any compensation for any purpose from the charter holder, the charter school, or a management company of the charter school, provide the information requested below: Amount of annual compensation $0.00. Reason for compensation:. 5. Current Employer: Belmont University Occupation: Associate Profesjor.
(12) 6. List all previous experience with charter schools. Include open-enrollment schools and/or campus or program charters: None DATES. CHARTER SCHOOL. ADDRESS. TITLE. 7. List all previous experience with any charter school management company: None MANAGEMENT COMPANY. DATES. ADDRESS. TITLE. ». . Is any relative within the third degree of consanguinity (i.e., your parent, grandparent, greatgrandparent, child, grandchild, great-grandchild, sibling, aunt, uncle, niece, nephew) or within the third degree of affinity (i.e., your spouse or your spouse's parent, grandparent, great-grandparent, child, grandchild, great-grandchild, sibling, aunt, uncle, niece, nephew) also a member of the charter holder governing body or charter school governing body? No LJ Yes. 0No. If yes, give details:. 9. Will any relative(s) within the third degree of consanguinity or affinity (see definitions in Question 8 above) be employed by or receive any compensation or remuneration from the charter holder or the charter school? No ClYes. 0No. If yes, give details:.
(13) 10. Have you ever been convicted of a misdemeanor involving moral turpitude or any felony?. DYes 0No. If yes, give details:. Dated and signed this 5^_day o/May_ 2007. / herby certify under penalty of perjury that I am acting on my own behalf, and that the foregoing statements are true and correct to the best of my knowledge and belief.. (Signature of Affiant). VERIFICATION State of Texas (cv r r- CUVT On this day :fy\lvM-^Q (name of affiant) appeared before me the undersigned notary public and deposed that he/she executeOThe above instrument and that the statements and answers contained therein are true and correct to the best of his/her knowledge and belief. Subscribed and sworn to before me this _1. ~> day of. . 20 o -7 Ltt&<. (Notary Public) (SEAL). My commission expires:—rL. / 7.
(14) TEXAS EDUCATION AGENCY. RENEWAL APPLICANT. BIOGRAPHICAL AFFIDAVIT. (MUST COMPLETE ONLINE VERSION, PRINT, and NOTARIZE). Check all that apply; 0Member of the governing board of the charter holder DMember of the governing board of the charter school (if a separate secondary board exists) Full Name of Charter Holder: (i.e., nonprofit corporation, institution of higher education, or governmental entity). East Fort Worth Montessori School, Inc.. Full Name of Charter School:. East Fort Worth Montessori Academy. In connection with the above-named organization and charter school renewal application, I make. representations and supply information about myself as hereinafter set forth. (Attach addendum or. separate sheet if space hereon is insufficient to answer any questions fully.). IF ANSWER IS "NO" OR "NONE", SO STATE. 1. Full Name (Initials Not Acceptable): Sandy Joyce 2. Have you ever had your name changed or used another name?. C]Yes. XNo. If yes, give reason for the change: _____ Maiden Name (if female): Other names used at any time: 3. If in addition to being a charter holder or charter school board member, you serve or are employed as an "officer of an open-enrollment charter school" as the term is defined in TEC § 12.1012(6), state your school officer position. 4. If you expect to receive any compensation for any purpose from the charter holder, the charter school, or a management company of the charter school, provide the information requested below: Amount of annual compensation $0.00. Reason for compensation:. _________^. 5. Current Employer: La Vida News the Black Voice Occupation: Writer/Photographer/editor. 1.
(15) List all previous experience with charter schools. Include open-enrollment schools and/or campus or program charters: CHARTER SCHOOL. DATES. ADDRESS. TITLE. 7. List all previous experience with any charter school management company: DATES. MANAGEMENT COMPANY. ADDRESS. TITLE. 8. Is any relative within the third degree of consanguinity (i.e., your parent, grandparent, greatgrandparent, child, grandchild, great-grandchild, sibling, aunt, uncle, niece, nephew) or within the third degree of affinity (i.e., your spouse or your spouse's parent, grandparent, great-grandparent, child, grandchild, great-grandchild, sibling, aunt, uncle, niece, nephew) also a member of the charter holder governing body or charter school governing body? LJYes. 0No. If yes, give details:. 9. Will any relative(s) within the third degree of consanguinity or affinity (see definitions in Question 8 above) be employed by or receive any compensation or remuneration from the charter holder or the charter school?. ElYes 0No. If yes, give details:.
(16) 10. Have you ever been convicted of a misdemeanor involving moral turpitude or any felony?. DYes 0No. If yes, give details:. Dated and signed this $_day of May 2007,1 herby certify under penalty of perjury that I am acting on my own behalf, and that the foregoing statements are true and co&eeH&jfa best of my knowledge and belief. VERIFICATION. State of Texas. On this day, (name of affiant) appeared before me the undersigned notary public and deposed that ne/she executed the above instrument and that the statements and answers contained therein are true and correct to the best of his/her knowledge and belief. cribed and sworn to before me this". (Notary Public) (SEAL). My commission expires ,.
(17) TEXAS EDUCATION AGENCY. RENEWAL APPLICANT. BIOGRAPHICAL AFFIDAVIT. (MUST COMPLETE ONLINE VERSION, PRINT, and NOTARIZE). Check all that apply: 0Member of the governing board of the charter holder n Member of the governing board of the charter school (if a separate secondary board exists) Full Name of Charter Holder: (i.e.. nonprofit corporation, institution of higher education, or governmental entity) Full Name of Charter School:. East Fort Worth Montessori School, Inc.. East Fort Worth Montessori Academy. In connection with the above-named organization and charter school renewal application. I make. representations and supply information about myself as hereinafter set forth. (Attach addendum or. separate sheet if space hereon is insufficient to answer any questions f u l l \ . ). IF ANSWER IS "NO" OR "NONE". SO STATE. 1. Full Name (Initials Not Acceptable): Robert Allen Scarborough 2. Have you ever had your name changed or used another name?. Yes. If yes, give reason for the change: Maiden Name (if female): Other names used at any time: 3. If in addition to being a charter holder or charter school board member, you serve or are employed as an "officer of an open-enrollment charter school" as the term is defined in TEC § 12.1012(6). stale your school officer position. 4. If you expect to receive any compensation for any purpose from the charier holder, ihe charter school, or a management company of the charter school, provide the information requested below: Amount of annual compensation SO.00. Reason for compensation:. 5. Current Employer: Scarborough Engineering. Inc. Occupation: Electrical Engineer. __^.
(18) 6. List all previous experience with charter schools. Include open-enrollment schools and/or campus or program charters: CHARTER SCHOOL. DATES. 2003-2005. Treetops School International. I11IJ-;. ADDRESS 12500 South Pipeline Huless, TX 76040. Parent. 7. List all previous experience with any charter school management compain: DATES. M A N A G K M K N 1' COMPANY. ADDRESS. TITLE. . Is any relative within the third degree of consanguinity (i.e.. your parent, grandparent, greatgrandparent, child, grandchild, great-grandchild, sibling, aunt, uncle, niece, nephew) or within the third degree of affinity (i.e.. your spouse or your spouse's parent, grandparent, great-grandparent, child, grandchild, great-grandchild, sibling, aunt, uncle, niece, nephew) also a member of the charter holder governing body or charter school governing body?. If ves, give details:. 9. Will any relativc(s) within the third degree of consanguinity or affinity (.we definitions in Question 8 above) be employed by or receive any compensation or remuneration from the charier holder or the charter school? DVes 0No. If yes, give details:.
(19) 10. Have you ever been convicted of a misdemeanor involving moral t u r p i t u d e or any felony?. DYes 0No. If yes, aive details:. Dated ami signed this 4th day of May 2002, I herby certify under penally of perjury I hat I urn acting on my own behalf, and thai the foregoing statements are true and correct to the best of my knowledge and belief.. VERIFICATION. State of Texas touni\ of JUc> o ^ CV(\ T. On this dav.^VC^Qg r-y l\Ug A S(Lc\rKot'bi^iv("ame of affiant) appeared before me the undersigned notary public and deposed that he/she executed the aoove instrument and that the statements and answers contained therein are true and correct to the best of his/her k n o w l e d e and belief. Subscribed and sworn to before me this"r"\ u. day of. • 20. £). 1. '. 0. (Notar\ Public) (SRAL). My commission e>.
(20) TEXAS EDUCATION AGENCY. RENEWAL APPLICANT. BIOGRAPHICAL AFFIDAVIT. (MUST COMPLETE ONLINE VERSION, PRINT, and NOTARIZE). Check all that apply: 0Member of the governing board of the charter holder QMember of the governing board of the charter school (if a separate secondary board exists) Full Name of Charter Holder: (i.e., nonprofit corporation, institution of higher education, or governmental entity) Full Name of Charter School:. East Fort Worth Montessori School, Inc.. East Fort Worth Montessori Academy. In connection with the above-named organization and charter school renewal application, I make representations and supply information about myself as hereinafter set forth. (Attach addendum or separate sheet if space hereon is insufficient to answer any questions fully.) IF ANSWER IS "NO" OR "NONE", SO STATE. 1. Full Name (Initials Not Acceptable): AyaNomura 2. Have you ever had your name changed or used another name?. EUYes. XNo. If yes, give reason for the change: Maiden Name (if female): Other names used at any time: 3. If in addition to being a charter holder or charter school board member, you serve or are employed as an "officer of an open-enrollment charter school" as the term is defined in TEC § 12.1012(6), state your school officer position. 4. If you expect to receive any compensation for any purpose from the charter holder, the charter school, or a management company of the charter school, provide the information requested below: Amount of annual compensation $0.00. Reason for compensation:. 5. Current Employer: City of Fort Worth Occupation: Cable Producer/Director.
(21) 6. List all previous experience with charter schools. Include open-enrollment schools and/or campus or program charters: DATES. CHARTER SCHOOL. ADDRESS. TITLE. 7. List all previous experience with any charter school management company: DATES. MANAGEMENT COMPANY. ADDRESS. TITLE. . Is any relative within the third degree of consanguinity (i.e., your parent, grandparent, greatgrandparent, child, grandchild, great-grandchild, sibling, aunt, uncle, niece, nephew) or within the third degree of affinity (i.e., your spouse or your spouse's parent, grandparent, great-grandparent, child, grandchild, great-grandchild, sibling, aunt, uncle, niece, nephew) also a member of the charter holder governing body or charter school governing body? I_J Yes. fcJ. If yes, give details:. 9. Will any relative(s) within the third degree of consanguinity or affinity (see definitions in Question 8 above) be employed by or receive any compensation or remuneration from the charter holder or the charter school?. If yes, give details:.
(22) 10. Have you ever been convicted of a misdemeanor involving moral turpitude or any felony?. DYes 0No. If yes, give details:. Dated and signed this 3_day of May 2007. / herby certify under penalty of perjury that I am acting on my own behalf, and that the foregoing statements are true and correct to the best of my knowledge and belief.. (Signature of Affiant). VERIFICATION. State of Texas Count1 of On this day, -Awn M<fr rv\ Ik r (X_ (name of affiant) appeared before me the undersigned notary public and deposed that he/she executed the above instrument and that the statements and answers contained therein are true and correct to the best of his/her knowledge and belief. Subscribed and sworn to before " me this. t5>. day of. vTV'JL-^_. , 20 Q ~/. (Notary Public) (SEAL). My commission expires. L1. ~/t//:Ktg. / /. ..
(23) TEXAS EDUCATION AGENCY RENEWAL APPLICANT BIOGRAPHICAL AFFIDAVIT (MUST COMPLETE ONLINE VERSION, PRINT, and NOTARIZE) Check all that apply: 0Member of the governing board of the charter holder QMember of the governing board of the charter school (if a separate secondary board exists) Full Name of Charter Holder: (i.e., nonprofit corporation, institution of higher education, or governmental entity) Full Name of Charter School:. East Fort Worth Montessori School, Inc.. East Fort Worth Montessori Academy. In connection with the above-named organization and charter school renewal application, I make. representations and supply information about myself as hereinafter set forth. (Attach addendum or. separate sheet if space hereon is insufficient to answer any questions fully.). IF ANSWER IS "NO" OR "NONE", SO STATE. 1. Full Name (Initials Not Acceptable):John J. Roberts 2. Have you ever had your name changed or used another name?. dYes. E^lNo. If yes, give reason for the change: Maiden Name (if female): Other names used at any time: None 3. If in addition to being a charter holder or charter school board member, you serve or are employed as an "officer of an open-enrollment charter school" as the term is defined in TEC § 12.1012(6), state your school officer position. No. 4. If you expect to receive any compensation for any purpose from the charter holder, the charter school, or a management company of the charter school, provide the information requested below: Amount of annual compensation $0.00 Reason for compensation:. 5. Current Employer: Paul Quinn College Occupation: College Registrar. _________^^^_.
(24) 6. List all previous experience with charter schools. Include open-enrollment schools and/or campus or program charters: CHARTER SCHOOL. DATES. ADDRESS. TITLE. None. 7. List all previous experience with any charter school management company: DATES. MANAGEMENT COMPANY. ADDRESS. TITLE. None. 8. Is any relative within the third degree of consanguinity (i.e., your parent, grandparent, greatgrandparent, child, grandchild, great-grandchild, sibling, aunt, uncle, niece, nephew) or within the third degree of affinity (i.e., your spouse or your spouse's parent, grandparent, great-grandparent, child, grandchild, great-grandchild, sibling, aunt, uncle, niece, nephew) also a member of the charter holder governing body or charter school governing body?. D Yes. 0No. If yes, give details:. 9. Will any relative(s) within the third degree of consanguinity or affinity (see definitions in Question 8 above) be employed by or receive any compensation or remuneration from the charter holder or the charter school?. LlYes 0No. If yes, give details:.
(25) 10. Have you ever been convicted of a misdemeanor involving moral turpitude or any felony?. DYes 0No. If yes, give details:. // w* Dated and signed this If day ofv^Vf 20 § *7 . / herby certify under penalty of perjury that / am acting on my own behalf, and that the foregoing statements are true and correct to the best of my knowledge and belief.. (Signature of Affiant). VERIFICATION. State of Texas. On this day, (name of affiant) appeared before me the undersigned notary public and deposed that he/sne executecTthe above instrument and that the statements and answers contained therein are true and correct to the best of his/her knowledge and belief. Subscribed and sworn to before me this. day of. / '£ *~3_. , 20 O. V. J. D. HURD. Notary Public. State of Texas. Comm. Expires 10 31-2008. (SEAL). (Notary Public) My commission expires.
(26) TEXAS EDUCATION AGENCY. RENEWAL APPLICANT. BIOGRAPHICAL AFFIDAVIT. (MUST COMPLETE ONLINE VERSION, PRINT, and NOTARIZE). Check all that apply: 0M ember of the governing board of the charter holder fjMernber of the governing board of the charter school (if a separate secondary board exists) Full Name of Charter Holder: (i.e., nonprofit corporation, institution of higher education, or governmental entity) Full Name of Charter School:. East Fort Worth Montessori School, Inc.. East Fort Worth Montessori Academy. In connection with the above-named organization and charter school renewal application, I make. representations and supply information about myself as hereinafter set forth. (Attach addendum or. separate sheet if space hereon is insufficient to answer any questions fully.). IF ANSWER IS "NO" OR "NONE", SO STATE. 1. Full Name (Initials Not Acceptable):Barbara Anne Shipman 2. Have you ever had your name changed or used another name?. LjYes. X No. If yes, give reason for the change: Maiden Name (if female): Other names used at any time: 3. If in addition to being a charter holder or charter school board member, you serve or are employed as an "officer of an open-enrollment charter school" as the term is defined in TEC § 12.1012(6), state your school officer position. 4. If you expect to receive any compensation for any purpose from the charter holder, the charter school, or a management company of the charter school, provide the information requested below: Amount of annual compensation $0.00. Reason for compensation:. 5. Current Employer: The University of Texas at Arlington Occupation: Associate Professor of Mathematics.
(27) 6. List all previous experience with charter schools. Include open-enrollment schools and/or campus or program charters: None CHARTER SCHOOL. DATES. ADDRESS. TITLE. 7. List all previous experience with any charter school management company: None DATES. MANAGEMENT COMPANY. ADDRESS. TITLE. . Is any relative within the third degree of consanguinity (i.e., your parent, grandparent, greatgrandparent, child, grandchild, great-grandchild, sibling, aunt, uncle, niece, nephew) or within the third degree of affinity (i.e., your spouse or your spouse's parent, grandparent, great-grandparent, child, grandchild, great-grandchild, sibling, aunt, uncle, niece, nephew) also a member of the charter holder governing body or charter school governing body? U Yes. 0No. If yes, give details:. 9. Will any relative(s) within the third degree of consanguinity or affinity (see definitions in Question 8 above) be employed by or receive any compensation or remuneration from the charter holder or the charter school? DYes 0No. If yes, give details:.
(28) 10. Have you ever been convicted of a misdemeanor involving moral turpitude or any felony?. DYes 0No. If yes, give details:. Dated and signed this third_tfay o/~May 2007, / herby certify under penalty of perjury that 1 am acting on my own behalf, and that the foregoing statements are true and correct to the best of my knowledge and belief.. (Signature of Affiant). VERIFICATION. State of Texas. On this day, t>yi- Wvr-Q -£>K *~y iV^X/vv (name of affiant) appeared before me the undersigned notary public and deposed that he/she executed the above instrument and that the statements and answers contained therein are true and correct to the best of his/her knowledge and belief. Subscribed and sworn to before me this '7. day of. i. , 20 O ~7. (Notary Public) (SEAL). My commission expires. I 7. 2.
(29) Section IV. Instructional Facilities. 19 TAC §100.1512 requires, among other things, that a charter holder comply with all state and local laws and ordinances applicable to the occupation and use of the facilities it occupies, including any special standards applicable to the instruction of public school students in the facilities. Submit, as Attachment 3, a certificate of occupancy or equivalent certificate for each site used as an instructional facility; and as Attachment 4, a completed Instructional Facilities Form(s) for each site that is operated under the charter. The online version of the Instructional Facilities Form(s) is located on the on-line resource page.. Intentionally Left Blank. 10.
(30) Attachment III. East Fort Worth Montessori School, Incorporated. Certificates of Occupancy. 10a.
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(34) Attachment IV. East Fort Worth Montessori School, Incorporated. Instructional Facilities Form. 10b.
(35) Instructional Facilities Form. Instructions: Complete, print, and submit the instructional facilities form with the renewal application. Please provide the following information concerning the local certifying agency that issues certificates of occupancy, or their equivalent, in the jurisdiction in which the charter school is located. Important: There must be one certificate of occupancy and one instructional facilities form per campus. Campus information Campus Name:. East Fort Worth Montessori Academy. (0 digit number, without dashes). Nine-Digit Campus Number:. Address of Campus:. 501 Oakland Boulevard; Fort Worth, Texas 76103. Local Certifying Agency Information Name of Certifying Agency:. City of Fort Worth, Development Department. Name of Contact Person at Certifying Agency:. Al Godwin. Telephone No. for Contact Person at Certifying Agency: Address of Certifying Agency:. 1000 Throckmorton Street; Fort Worth, Texas 76102. List any special requirements that the local certifying agency has for the instructional facilities. None. List any other pertinent information.. None.
(36) Section V. Teacher Qualifications The requirements for certain teachers changed in 2002 with the passage of the No Child Left Behind Act (NCLB). The NCLB requires charter school teachers assigned to teach core academic subject areas (i.e., English, reading or language arts, mathematics, science, foreign languages, civics and government, economics, arts, history, and geography) to be "highly qualified." To be "highly qualified," a teacher assigned to teach a core academic subject area must hold a bachelor's degree and demonstrate competency in each area of assignment. (For more information about required teacher qualifications, please see the publications of the NCLB Bulletin, available via the on-line resource page). Charter school teachers assigned to teach subjects that are not considered core academic subject areas under the NCLB must meet the state law requirement of a high school diploma. Furthermore, state law and rule require charter school teachers assigned to teach special education, bilingual education, and English as a second language to be certified. Many charter schools require their teachers to have additional qualifications beyond the minimum requirements of federal and/or state law. A. In the space below, please set forth the qualifications that the charter school requires for teachers assigned to teach core academic subject areas (i.e., English, reading or language arts, mathematics, science, foreign languages, civics and government, economics, arts, history, and geography). Type Below: Our teaching staff is required to demonstrate competency in core academic areas to meet with the No Child Left Behind criteria of "highly qualified". As a Montessori School, teachers must have a Montessori Certification or degreed teachers who are in the process of obtaining their Montessori certification. We encourage all of our staff to continue their education with Master Degrees and other certifications such as ESL and Special Education Certifications.. B. In the space below, please set forth the qualifications that the charter school requires for teachers assigned to teach subjects that are not considered core academic subject areas under the NCLB. Type Below: Our Educational Aids that have been with the school since it began have met rigourous standards of quality and can demonstrated by taking a class and assessment of knowledge by our Regional Service Center. New hires are required to have a high school diploma and studying at a higher education institution working toward their Associates Degree while employed, by EFWMA.. 11.
(37) C. In the space below, please set forth the qualifications that the charter school requires for teachers assigned to teach special education.. Type Below:. Special education students are taught by a Texas Certified Special Education Teacher.. C. In the space below, please set forth the qualifications that the charter school requires for teachers assigned to teach bilingual education and/or English as a second language. Type Below: English as a Second Language students are taught by a Texas Certified English as a Second Language Teacher. We do not have a bilingual education program at this time, however, we are endeavoring to hire a Texas Certified Bilingual Teacher. We are working closely with our Regional Service Center to hire a bilingual teacher from Mexico.. Intentionally Left Blank. 12.
(38) Section VI. Compliance with Complaint Procedures The charter holder board chair must sign below to acknowledge that: (1) the governing body(ies) and school officers are aware that 19 TAC §100.1033(c)(6)(C)(i) states that the governing body of a charter holder shall not delegate final authority to hear or decide employee grievances, citizen complaints, or parental concerns; and (2) the governing body of the charter holder is in compliance with the above requirement.. Signature of Charter. (must sign in blu\. Intentionally Left Blank. 13.
(39) Section VII. Admissions Policy. A. Specify the period during which applications for admission are accepted. TEC, §12,117, requires that a charter school establish a reasonable application deadline for the submission of applications for admission.. Beginning of Period. End of Period. February 1 (Month/Day). March 31 (Month/Day). B. If the school admits students by lottery when the number of admissions applications received exceeds the number of available spaces, describe the procedures followed in conducting the lottery. Type Below: All registration entries are placed in a receptacle and are blindly drawn from the container until the receptacle is empty. Each registration is assigned a number as they are drawn. Vacancies are filled for the upcoming school year in the order they were chosen. Those registrations which do not fulfill a vacancy become the waiting list. When a vacancy becomes available during the school year, we contact the next person on the waiting list.. C. If the school utilizes a lottery when oversubscribed, are any categories of applicants exempted from the lottery? Check one:. No HH Not applicable (because lotteries are not utilized) If "Yes" was indicated in C above, state the categories of applicants that are exempted. Type Below:. D. If the school utilizes a lottery when oversubscribed, specify the approximate date on which a lottery will be conducted.. Approximate Date of Lottery (April 30). E. If the school does not utilize a lottery when oversubscribed, but rather fills the available positions in the order in which applications were received before the expiration of the application deadline (i.e., a "first-come, first-served" admission process), describe the manner in which the school notifies the community of the opportunity to apply for admission. TEC, §12.117, requires a charter school that uses a first-come, first-served admission process when oversubscribed to publish a notice in a newspaper of general circulation not later than the seventh day before the application deadline. Type Below:. 14.
(40) Describe the information that an applicant must provide in order to be considered for admission. Applicants may not be required to provide copies of transcripts or other academic records until after they are offered admission and are enrolling. Furthermore, a student may not be precluded from enrolling due to the charter school's failure to receive information required for enrollment from the student's parent or guardian or previous school. See TEC, §25.002. Type Below: Applicants must complete the Registration Form. They must provide us with a Birth Certificate, a utility bill, a Social. Security Card (if they have one), and fill out an income statement if they wish to enroll their child in pre-kindergarten.. G. The charter holder certifies that the non-discrimination statement required by TEC, § 12.11 l(aX6) is printed in the school's admission policy. TEC, §12.111(6) requires that a charter school's admissions policy include a statement that the school will not discriminate in admissions based on gender, national origin, ethnicity, religion, disability, academic, artistic, or athletic ability, or the district the child would otherwise attend. Check one: 0 Yes. n NO. H.. Does the admissions policy either require or permit the school to exclude from admission all students with documented histories of a criminal offense, a juvenile court adjudication, or discipline problems under TEC Chapter 37, Subchapter A as authorized by TEC, § 12.11 l(a)(6)? Check one: 0 Yes (The school excludes such students or reserves the right to exclude such students from admissions.) n No (The school does not deny admission to such students based on their documented histories of misconduct.). I. Submit • as Attachment 5, a current copy of the admissions policy that incorporates the information provided in the above answers to questions A through H and any other relevant information; • as Attachment 6, a blank copy of the current admissions application (i.e., the information requested when the student first seeks admission); and • as Attachment 7, a blank copy of the current enrollment form(s) (i.e., the information required once an applicant has been offered admission and is registering for enrollment).. Intentionally Left Blank. 15.
(41) Attachment V. East Fort Worth Montessori School, Incorporated. Admission Policy. 15a.
(42) •REVISED DURING CONTINGENCY PROCESS.. ENROLLMI THE USE OF\A PUBLIC LOTTERY SYSTEM/admits students to the East Fort Worth Montessori AcademySEach year applications for the tottepf will be open from Feb 1 to March 31. There will be a lottery held tochoose from random, names ofAidents to fill any vacancies in the school on or about April 30. This lottery will only consist of names of students who qualify for the grade or age level to which the school has openings. Students currency enrolled at EFWMA are guaranteed a place at the school for the remaining years ibey are eligible provided they are adhering to the policies of the school. Siblings are not automatically accepted based upon their brother or sister continuing enrollment. East Fort Worth Montessori Academ^has an admission policy which does not discriminate on the basis of sex, national origin, ethnicity, religbnNdfsability, academic, artistic, or athletic ability, or the district the child would otherwise attend in accorefanfee with this code, although the charter may provide for the exclusion of a student who has a dooumentedJhistory of a criminal offense, a juvenile court adjudication, or discipline problems under Subcl>apter A, Chester 37. THE WAITING LIST is fflte6 with students who^Sre not selected through the lottery process and will remain on the waiting list for me remainder of the schocWar for which they applied.. ADMISSION PROCEDURE 1. Child is7selected through lottery process (Sekabove) One ar both parents visit the school preferableVith their child Completion of all forms in the Registration package plus copies of: Social Security card Birth Certificate, Updated immunization record 4./ Signed medical reports detailing your child(ren)'s allergies. Children must be toilet trained.. East Fort Worth Montessori Academy Student Handbook, Volume Five, Page 6.
(43) APPROVED DURING CONTINGENCY PROCESS. School Policies ENROLLMENT THE USE OF A PUBLIC LOTTERY SYSTEM admits students to the East Fort Worth Montessori Academy. Each year applications for the lottery will be open from Feb 1 to March 31. There will be a lottery held to choose from random, names of students to fill any vacancies in the school on or about April 30. This lottery will only consist of names of students who qualify for the grade or age level to which the school has openings. Students currently enrolled at EFWMA are guaranteed a place at the school for the remaining years they are eligible provided they are adhering to the policies of the school. East Fort Worth Montessori Academy has an admission policy which does not discriminate on the basis of sex, national origin, ethnicity, religion, disability, academic, artistic, or athletic ability, or the district the child would otherwise attend in accordance with this code, although the charter may provide for the exclusion of a student who has a documented history of a criminal offense, a juvenile court adjudication, or discipline problems under Subchapter A, Chapter 37. THE WAITING LIST is filled with students who are not selected through the lottery process and will remain on the waiting list for the remainder of the school year for which they applied.. ADMISSION PROCEDURE 1. Child is selected through lottery process (See above) 2. One or both parents visit the school with their child 3. Completion of all forms in the Registration package plus copies of: S Social Security card v' Birth Certificate, v' Updated immunization record 4. Signed medical reports detailing your child(ren)'s allergies.
(44) Attachment VI. East Fort Worth Montessori School, Incorporated. Admission Application. I5b.
(45) East Fort Worth Montessori. Home Phone NumberX. Middle Name. First Name. Student's Suman<*e (Last). Social Security Number. Enrolling Grade. Closest Elementary School to your home. Primary Contact Person Sumamex. a.. Blrfn date. City If not FW,. Student' s Physical AddressN. Persona! email Address. M / F Gender. Preferred Name. Relation to Child. First Name. \. Zip Code. Phone Number. Cell Phone Number. Work Phone. How did you hear about the school? Part 1: Food Stamp or TANF case # (if anyX Part 2: The Pr&Kindergarten Program requires each household to give an income statement prior to enrollment. 1. Name (List everyone in the household) 2. Income and how often it is received from each person living in your household Place income amount and letter after the amount, vyeekly (W), Monthly (M), Eyery 2 Weeks (E), Twice a Month (T) Earnings from Work Welfare, Child Pensions, Retirement No Name of Member in Household before deductions\ Support, alimony/ Social Security Other Income. 1.. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.. $ \ ' / $ $ / $ \ '/ $ / $ * V $ / $ $ $ / $ / '\ $ / $/ / Ns* $ $ / $ / N ' S / / ' \ ' $ $ / / / * V $ $ / $ * \ / $ / / * '\ $ $ / \ ,* ' / ' \ $. /. *. /\. $. /. $. /. $. /. $. /. $. /. $. /. $. /. $. /. $. /. $. /. / / / / / / / / / / / '. n a a a a a a a a a D. a. EFWMA prohibits discrimination iryfs admission policy on the basis of sex, national origin, ethnicitV religion, disability, academic, or athletic ability or the district the student would otherwise attend. Non disclosure or falsification cinformation on this document will terminate the application p; JSS. La matriculacion sera determinado segun el orden en que van Itegando las apticaciones. La escuela de^East Fort Worth Montessori Academy probine qualqujer discriminacion en el proceso de admission por motives de sexo, origen, naojonalidad, grupo etnico, religion, o inhanilidades aca/emicas, o athleticas. La falsificacion o omission de informacion en este docume\to anulara el proceso de inscripcion.. For School use only. D Completed Campus Tour^ D Explanation of Policies. D Copy of Birth Certificate D Copy of Utility Bill for proof of Geographic Boundary. D Monthly Income:. D Household Size:. D Copy of Social Security Card. D TANF;. D Eligibility.
(46) East Fort Worth Monte. APPROVED DURING CONTINGENCY PROCESS. Application. Students Surname (Last). Middle Name. First Name. City If not FW,. Student' s Physical Address. Home Phone Number. Preferred Name. Enrolling Grade. Social Security Number. Primary Contact Person Surname. Relation to Child. First Name. Birthdate. Phone Number. Work Phone. Personal email Address. Zip Code. Cell Phone Number. Place of Employment. How did you hear about the school?. Please fill out the form below if you are enrolling your child in the Pre-kindergarten program. If applying for the P re-Kindergarten program, the law requires each household to give an income statement prior to enrollment. 1. Name (List everyone in the household) 2. Income and how often it is received from each person living in your household. Place income amount and letter after the amount. Weekly (W), Monthly (M), Every 2 Weeks (E), Twice a Month (T). Name of Member in Household. 1.. Earnings from Work before deductions. Welfare, Child Pensions, Retirement,) Support, alimony Social Security. No Income. Other. D. $. /. $. /. $. /. $. /. $. /. $. /. $. /. $. /. $. /. $. /. $. /. $. /. $. /. $. /. $. /. $. /. $. /. $. /. $. /. $. /. 2.. D. 3.. D. D. 4. 5.. D. 6.. Household Size:. D. $ Total:. /. $ Total:. /. $ Total:. /. $ Total:. /. = $. EFWMA prohibits discrimination in its admission policy on the basis of sex, national origin, ethnicity, religion, disability, academic, or athletic ability or the district the student would otherwise attend. However, EFWMA provide for the exclusion of a student who has a documented history of a criminal offense, a juvenile court adjudication, or discipline problems under TEC,12.111(a)(6). Non disclosure or falsification of information on this document will terminate the application process. La matriculacion sera determinado segun el orden en que van llegando las aplicaciones. La escuela de East Fort Worth Montessori Academy proibe qualquier discriminacion en el proceso de admission por motives de sexo, origen, nacionalidad, grupo, etnico, religion, o inhabilidades academicas, o athleticas. Sin embargo, EFWMA exculge a un estudiante que tenga un historial de crime, una sentenciq de la corte juvenile a problemas de disciplina bajo la seccion 12.111(a)(6). La falsificacion o omission de informacion en este documento anulara el proceso de inscripcion..
(47) Attachment VI. East Fort Worth Montessori School, Incorporated. Enrollment Form. I5c.
(48) East Fort Worth Montessori Academy Enrollment Form First Name. Surname (Last) Home Phone Number. OFFICE USE ONLY _ Social Security Card _Photo Release Form . Birth Certificate __Field Trip Release _UnHorm Agreement _ Immunizations .Handbook _Home Language ^Registration Form _Mlgrant Form Information Release Original Enrollment Date:. Middle Name. Preferred Name. Social Security Number Enrolling Grade Closest Elementary School to your home. Student s Physical Address. City If not FW,. Ethnicity: {Circle one) 01 American Indian. Zip Code. 02 Asian/Pacific Islander. 03 Black, not of Hispanic Origin. First Name. Relation to Child. Primary Contact Person Surname. Secondary Contact Person Surname. First Name. Relation to Child. Work Phone. Personal email Address. Birth date. Language spoken in the home. 04 Hispanic 05 White, not of Hispanic Origin. Phone Number. Cell Phone Number. Place of Employment. Work Phone. Personal email Address. M / F Gender. Phone Number. Cell Phone Number. Place of Employment. How did you hear about the school? Are there orders affecting custody of this student? D No D Yes, Are there any restraining orders? D No D Yes. Name of Person^. Student may be released to: DFather D Mother DOther. has custody. Relation: DOther. Password: This is a way to verify that the person calling the school can make changes over the phone or for someone to use to pick up your child in the case of an emergency. Are you enrolled in the Even Start Program? D Yes D No. PERSON(S) TO CALL IN EMERGENCY WHEN PARENT CANNOT BE REACHED: Name. Relation to Child. Phone Number. Secondary Phone Number. Name. Relation to Child. Phone Number. Secondary Phone Number. Name. Relation to Child. Phone Number. Secondary Phone Number. Name of Person(s) or Day Care Authorized to Pick Up Your child(ren) with Contact Phone Number L; Daycare ; I Individual Name. Phone Number. Secondary Phone Number. Name. Phone Number. Secondary Phone Number. Name. Phone Number. Secondary Phone Number. LJ Daycare u Individual j Daycare. j Individual. In the event emergency medical attention is needed, I give my full permission for transportation and/or any medical services to be rendered to my child by the attending emergency room physician(s) or speciafist(s). Signature Date EFWMA prohibits discrimination in its admission policy on the basis of sex, national origin, ethnicity, religion, disability, academic, or athletic ability or the district the student would otherwise attend. Non disclosure or falsification of information on this document will terminate the application process. La matriculacion sera determinado segun el orden en que van Itegando las aplicaciones. La escuela de East Fort Worth Montessori Academy probine quatquier discriminacion en el proceso de admission por motives de sexo, origen, nacionalidad, grupo etnico, religion, o inhanilidades academicas, o athleticas. La falsification o omission de informacion en este documento anulara el proceso de inscripcion..
(49) East Fort Worth Montessori Academy Authorization for Release of Student Records In accordance with the Family Educational Rights and Privacy Act of 1974 and Texas State Law, please release to East Fort Worth Montessori Academy all records, including. • Cumulative record • Transcripts of completed work including grades to date. • Health records • Any other educational information • Special Education records including: ARD's, lEP's, ITP's, BIP's, academic assessments, audio logical, speech and language assessments, medical reports, psychological evaluations and any additional pertinent information. Parent/Legal Guardian. Signature Date. East Fort Worth Montessori Academy Uniform Agreement Uniforms are a great equalizer. Every child is required to come to school in complete uniform each day. There will be NO substitutions. Uniform tops are plain t-shirts or golf shirts which are Forest Green, Navy Blue, Red in color. Blue jeans or blue pants or skirt. No boots, high heel shoes or open toe sandals are allowed. Fourth Grade: Long khaki pants, light blue button down shirts. Please contact the school Director if you are financially unable to purchase uniforms. I, (Parent Name) , have read and understand the uniform guidelines of EFWMA Charter School. I understand that if at any time my child is not in proper uniform, I will be notified by the school to bring proper attire or to pick him/her up for the rest of the day. Student Name:. ___. Parent Name:. Parent Signature:. Date:. East Fort Worth Montessori Academy Parents' Permission, Release and Indemnity for Field Trips I hereby certify that my Daughter/son Student Name has my permission to participate in all school sponsored Field Trips with EFWMA for the school year 2006-2007. I agree and do hereby waive and release all claims against the East Fort Worth Montessori Academy, Director, Board Members and any teacher, employee or other person engaged in the activity in question and agree to hold them harmless form any and all liability relating to my daughter/ son for any personal injury or illness that may be suffered or any loss of property that may occur to my daughter/ son. It is understood that no child will be allowed to participate in this activity until this form is signed by his/her, parent or guardian. Parent Signature. Date:. East Fort Worth Montessori Academy Information Release I grant EFWMA to publish the following information in a directory: Parent Name Address Student Name Email Address _l do not grant permission for any information published. Telephone No. East Fort Worth Montessori Academy Photo Release I hereby grant the East Fort Worth Montessori Academy and all related entities, full and absolute permission and all rights to copyright, publish, display and use for any legal purpose, any or all photographs, video tapes, and electronic images together with descriptive text or statements in which my child, (Student Name) may appear. EFWMA has the right to use these images for the benefit of the school as they see fit, without compensation to the student or parents. This includes but is not limited to, brochures, newsletters, and print media. Date: Signature of Parent or Guardian. . It is a criminal offense to falsify information on forms required for student registration. A person who knowingly I | falsifies information on a form required for enrollment shall be liable to the district and may be charged the maximum • tuition fee. {Texas Education Code 25.001 (h), Penal Code 37.10} I I certify that all the information on this enrollment form is true to the best of my knowledge. Parent/ Guardian Sionature. Home Phone Number. Work Phone Number. I.
(50) East Fort Worth Montessori Academy Home Language Survey Name First/ Primer Nombre/Vorname/Prenom/Ten hoc SID/HMH. Last/Apellido/Familienname/ Nom de famille/ Ten hoc sinh /. Grade Grade/ Klasse/ Classe/ Lop/ copra: 1 . What language is spoken in your home most of the time? Spanish: gQue idioma se habla en su casa la mayoria del tiempo? German: Welche Sprache wird in threm Heim meistens gesprochen? French: Quel on parie la langue dans votre maison la plupart du temps? Vietnamese: Thong thircmg gia dinh noi tieng gia nha? Russian: HTO asbiKa roBOpar B BaiiicM AOMaiiiHeM GoJibiUHHcree. 2. What Language does your child (do you) speak most of the time?. Spanish: £Que idioma se habla su hijo/hija (usted) la mayoria del tiempo?. German: Welche Sparche Ihr Kind tut (sprechen Sie) der grosste Teil der Seit?. Welche Sparche Ihr Kind macht, macht (Sie) sprechen Sie meistens? French: Quelle langue votre enfant (fait-il vous) parlez la plupart du temps? Vietnamese: Thiron ngay hpc sinh noi tieng gl ? Russian: KaKOM Jt3biK saiii peSeHOK (Resiacr, BU ) rosopHre SOJIHIUHHCTBO Signature of Parent or Guardian (PK-8, or student in grades 9-12) Spanish: Firma del padre o tutor (grades K-8,o alumno grades 9-12} German: Etter Oder vormund (klassen PK-8), Schuter (Klassen 9-12) French: Parent ou Tuteur de la classe de Jardin d'Enfantes, a la ctasse 8 (doue quatrieme) ou Etidient de la classe 9-12 (de troisieme a la classe terminale) Vietnamese: Tuirlap Chua dj KaO Giao den lap 8; Tu lap 9 den lap 12 (Phu huynh hoac Giam ho) (Ph(j huynh hoac hpc sinh) Russian: FIo^nHCb po^nrejia HJIH onenyHa, copra K-8, noflrmcb cryAem-a, copra 9-12 Date/ Fecha/ Datum/ date/ Ngay Thang/. Date entered the US (if born outside of US):_ Spanish: Fecha de entrada en los Estados Unidos German: Das Atum ist in USA gekommen (Wenn ist auBer USA) erregt French: La date est entree aux EU (si ne a I'exterieur des Estats-Unis) Vietnamese: Ngay mahoc sinh den Hoa-Ky neu sanh ngodi nuac My. Russian: ^ara Bouuia B C11IA ( CCJIH poacaeHO BHC CUIA ).
(51) Educational Student Background Previous Schools Attended: Independent School District. School Name. City, State. Years. Grades Retained?. Independent School District. School Name. City, State. Years. Grades Retained?. Independent School District. School Name. City, State. Years. Grades Retained?. Is your child currently being served in the Gifted and Talented Program at their previous school? Yes n tf yes, please describe the services provided, where and when.. Is your child currently being served in the ESL/Bilingual Education Program at their previous school? YesP If yes, please describe the services provided, where and when.. No D. No Q. Is your child currently being served in the Special Education Program at their previous school or is being served by: MHMR? YesD NoO ECI? YesDNoD PPCD? YesDNoD If yes, please describe the services provided, where and when.. This student has the following handicapping code/condition: a Learning Disabled (LD) D Emotionally Disturbed (ED). D Mentally Retarded (MR). D Other:. Migrant Education Eligibility Checklist EFWMA is helping the State of Texas identify students who may qualify for the Migrant Program that provides extra help in academics. Please answer the following questions: 1. Has your family moved any time during the last three years from one school district to another in Texas or to another state?. No a Yes a 2. Were any of these moves made to find temporary or seasonal work in agriculture related to job packing, processing, dairy work, forestry, fishing, etc.? nNo D Yes If yes, please complete the information below: Name of Parent/ Guardian. _^____. Address: ^. Age. Phone Number. Also, list names and ages of children who are not enrolled in school. Last First. Middle. Handbook Acknowledgement _(parent name) acknowledge receipt of the current EFWMA Handbook. I will review this handbook with my child (ren) and follow the policies and procedures therein: Child Name:. Child Name:. Child Name:. Child Name:. Parent Signature. Date.
(52) Student Name: ________. __. Part 1: Food Stamp or TANF case # (if any): Part 2: The Pre-Kindergarten program requires each household to give an income statement prior to enrollment. 1. Name (List everyone in the household) 2. Income and how often it is received from each person living in your household Place income amount and letter after the amount. Weekly (W), Monthly (M), Every 2 Weeks (E), Twice a Month (T) Earnings from Work Welfare, Child Pensions, Retirement No Name of Member in Household before deductions Support, alimony Social Security Other Income D 1. $ / $ / $ / $ / 2.. $. /. $. /. $. /. $. /. n. 3.. $. /. $. /. $. /. $. /. D. $. /. $. /. $. /. $. /. a. $. /. $. /. $. /. $. /. a. $. /. $. /. $. /. $. /. D. $. /. $. /. $. /. $. /. n. $. /. $. /. $. /. $. /. $. /. $. /. $. /. $. /. a. a. $. /. $. /. $. /. $. /. a. $. /. $. /. $. /. $. /. D. $. /. $. /. $. /. $. /. a. 4.. 5.. 6.. 7.. 8.. 9.. 10.. 11.. 12.. List any siblings attending the school: ! I. Name. Relationship. List all known allergies: (medication, food, insects etc.) List all medication:. If students need to receive medication during school hours, please pick up a form from the front office. Please make a note that the school will not give children over the counter medications only prescribed medication. Do not fill out this part. Monthly Income:. _. Household Size:. For School use only.. FS/TANF:. Eligibility:.
(53) Section VIII. Special Education Assurances. The charter holder certifies that it has policies and procedures in place that ensure implementation of all federal laws and regulations, Texas laws, State Board of Education (SBOE) and commissioner rules related to students with disabilities and further certifies that any future amendments to the laws, regulations, and rules will be incorporated and implemented.. Signature of Charter Hoi (mast sign in blu. Date. Intentionally Left Blank. 16.
(54) Section IX. Bilingual Education/ESL, Section 504, and Dyslexia Assurances. TEC, Chapter 29, Subchapter B, TEC §12J04(b)(2)(G), and 19 TAC §§89.1201-.1265 require charter schools to identify limited English proficient students based on state criteria and to provide an appropriate bilingual education or English as a second language program conducted by teachers certified for such courses. A. The charter holder certifies that it has policies and procedures in place that ensure that it complies with the legal and regulatory requirements concerning identifying and providing appropriate educational services to limited English proficient students. Check one: 0 Yes. DN O. Section 504 of the Rehabilitation Act of 1973, 29 V.S.C. §794, prohibits discrimination on the basis of disability in any program receiving federal financial assistance. A recipient that operates a public education program or activity shall provide a free, appropriate public education to qualified individuals. B. The charter holder certifies that it has policies and procedures in place that ensure that it complies with the legal and regulatory requirements concerning identifying and providing appropriate educational services to students protected by Section 504. Check one: 0 Yes. DNo. TEC §38.003, TEC§l2.l04(b)(2)(K), 19 TAC §74.28 and Section 504 of the Rehabilitation Act of 1973, 29 V.S.C. §794, require charter schools to identify students with dyslexia or related disorders and to provide appropriate educational services. C. The charter holder certifies that it has policies and procedures in place that ensure that it complies with the legal and regulatory requirements concerning identifying and providing appropriate educational services to students with dyslexia or related disorders. Check one: 0 Yes. DNo. I the undersigned hereby certify that the information contained hi this document is, to the best of my knowledge, correct and that the governing body of the charter holder has authorized me to provide these assurances.. Signature of Charter Holder^ (must sign in blue. 17.
(55) Section X. Certificate of Acknowledgement This section requires at least a majority of the governing body of the charter holder to certify that it has had an opportunity to review the completed renewal application and has authorized, during an open meeting, submission of the application to the commissioner for consideration of renewal of the charter.. CERTIFICATE OF ACKNOWLEDGEMENT The undersigned members of the governing body of the charter holder hereby acknowledge that they have had an opportunity to review the completed renewal application and have authorized its submission, during an open meeting, to the commissioner for consideration of the renewal of the charter: *Members are to sign the acknowledgement during an open meeting; therefore, the date next to each signature should be the same Typed Name (type name next to corresponding signature).. Signature (must sign in blue ink). 18. Date'.
(56) TEXAS EDUCATION AGENCY. 1701 North Congress Ave.* Austin. Texas 78701-1494* 512/463-9734* FAX: 512/463-9838 * http://www.lea.staie.tx.us. Charter Renewal November 2, 2007 Robert Scarborough, Chair East Fort Worth Montessori Academy 2717 Putnam Street. Fort Worth, TX 76112 Re: Charter Renewal for East Fort Worth Montessori Academy (CDN 220811) Dear Robert Scarborough: I am pleased to inform you that the charter renewal is approved for £ast Fort Worth Montessori Academy with a contract ending date of July 31, 2017. After renewal, the charter contract shall consist of the following: •. the representations and assurances made by the charter holder in the original request for application under the standard application system;. •. the original contract for charter, as signed by the charter holder and the State Board of Education;. •. any condition, amendment, modification, revision, or other change to the charter approved by the State Board of Education or the commissioner of education;. •. the final renewal application, on file with the Division of Charter Schools, including any revisions required by the agency and any amendments to the charter made through the renewal application; and. •. all statements, assurances, commitments and representations made by the charter holder in its application for charter renewal and its attachments or related documents, to the extent that these documents are consistent with those listed above.. Note that this contract is contingent upon legislative authorization and that the contract and the funding under state and federal law may be modified or even terminated by future legislative act. Furthermore, state and federal laws and rules may periodically be adopted, amended, or repealed and all such changes applicable to the charter holder or its charter school(s) may modify this contract, as of the effective date provided in the law or rule. Nothing in this contract shall be construed to entitle the charter holder to any privilege or benefit, including any funding, but in accordance with state and federal laws in effect and as they may in the future be amended. A contract term that conflicts with any state or federal law or rule is superseded by the law or rule to the extent that the law or rule conflicts with the contract term..
(57) Robert Scarborough, Chair East Fort Worth Montessori Academy Page 2 To acknowledge acceptance of this renewed contract, the chair of the charter holder board must sign below and return the entire original document to: Texas Education Agency Division of Charter Schools William B. Travis Building, Room 5-107 1701 North Congress Avenue Austin, Texas 78701-1494 The charter holder should keep a copy of the document for its files. Please contact the Division of Charter Schools at (512) 463-9575 with any questions. Sincerely,. Robert Scott Commissioner of Education cc: Joyce Brown, Superintendent. rs. I the undersigned hereby certify that the governing body of the charter holder has accepted and agreed to the charter renewal agreement for East Fort Worth Montessori Academy as outlined in the foregoing letter and has authorized me to sign below. Agreed and Accepted:. Robert Scarborough Chair, East Fort Worth Montessori Academy. Date.
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