Willow Creek Charter School

Willow Creek Charter School

FOR OFFICE USE ONLY:

2100 Willow Creek Road Prescott, Arizona 86301 Application Received: __________ Phone: 928-776-1212 Fax: 928-776-0009 First Day of Attendance: ________

School website: www.willowcreekcharter.com Sibling Yes No

e-mail: [email protected] IEP Yes No

See Teacher Profiles on file at the front desk and on our website Records req:_______ SPED req:________ Please provide a birth certificate and Records rec:_______ SPED rec:________ immunization records with your application. Date and Initial Entry into School Master

*WCC does not discriminate based on race, creed or gender _____________ ___________________ SAIS #______________________________

Willow Creek Charter School Student Application

Last name: ______________________________First name: _____________________ Middle: _______________ Home Phone: ___________ Mother cell: _____________ Father cell: _________ email: _______________________ Legal last name if different: ____________________________________________ Sex: _________________________ Physical Address: __________________________________________________ Birthdate: _______________________ City: _____________________________ State: ___________ Zip: __________ Social Security: __________________ Mailing Address: ____________________________________________________ Birth Place: ____________________ City: ____________________________ State: ________________ Zip: ____________________

Last school attended: _____________________________ Current Grade: _________ Date Withdrawn: _____________ Last School Address: ______________________________ City_____________ State _______ Zip _______________ FAMILY DATA

Full Name Last First Student Lives With

Has Legal Custody

Place of Employment Business phone

Father Mother Stepfather Stepmother Legal Guardian Foster

Names and Levels of Siblings attending WCC:

How did you hear about our school? __________________________________________________________________ Home Language Survey:

What is the primary language of the student?  English  Spanish  Other ______________________ Medical Survey: List any known allergies __________________Can your child be given cough drops?  Yes  No Can your child be given Advil or Tylenol?  Yes  No Can your child be given Tums?  Yes  No

Is this student Hispanic/Latino? (Choose one)  Yes  No

The above part of the question is about ethnicity, not race. No matter what you selected above, please continue to answer the following by checking one or more boxes to indicate what you consider your student’s race to be.

What is the student’s race? (Choose one or more)

 American Indian/Alaska Native  Asian  Black/African American  Native Hawaiian/Pacific Islander  Caucasian (White)

Does your child have a current I.E.P.?  No  Yes, if yes,parent must provide copies of this and sign the Records Release form attached.

Has the student ever been retained?  No  Yes, What year? __________________________________

Expulsion/Suspension: To the best of my knowledge, I am not aware of any expulsion, suspension, or non-compliance with a condition of disciplinary action imposed by another school or school district, or with a condition imposed by the Juvenile Court. True ______ False _____ If False, you must explain __________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ As a parent/guardian, I understand that acceptance for enrollment will be revoked upon finding the existence of any of the above conditions in this box. Initials ________

Emergency Contact Info: Please list two names and numbers of people we may call in case of an emergency if the parents or guardians are not available

1. _______________________________________________________________________________________________ 2. _______________________________________________________________________________________________

Divorce: Yes ___ No ___ If there is a Divorce or Legal Separation, please provide custody papers.

We will assume both parents have custody of the child unless indicated to the contrary, and that both parents may pick up the child. If this is not applicable to your situation, please indicate below who MAY and who MAY NOT pick up your child and attach any legal documentation.

MAY: Name Relationship Phone

________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

MAY NOT: Name Relationship Phone

________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

I/WE understand that all portions of this application must be completed for my/our child to be enrolled. I/WE hereby certify that the information provided in this application is true and complete.

I/WE understand and agree to the provided Parent/Student Handbook and will follow the new attendance policy ……..established 2009-2010 school year.

I/We understand that if our student is entering kindergarten for the school year there is now a $8.00 per day tuition fee. The State of Arizona pays for a kindergarten student to attend half day, the tuition covers the other half of the day.

Student Signature _____________________________________________________ Date ______________________

Willow Creek Charter School

2100 Willow Creek Road Prescott, Arizona 86301 Phone: 928-776-1212 Fax: 928-776-0009

e-mail: [email protected]

Terese Soto -Director

I hereby authorize__________________________________ school/district, to release

all

cumulative records (copies only) for ______________________________________ and

to be forwarded to the Willow Creek Charter School. I understand that any special

education records must be separately requisitioned (please see below). Thank you for

your help.

_____________________________________

______________

(Signature)

(Date)

*Records: Please include birth certificate, immunizations and hearing and vision

screenings.

---

I hereby release special education records for__________________________________

to be sent to Willow Creek Charter School. Thank you for your assistance.

_______________________________________

_______________

(Signature)

(Date)

FOR OFFICE USE ONLY:

SAIS #___________________ Date of Birth___________________ First Day of Attendance____________________

Date CUM & SPED 1st Request _________ 2nd Request_________ 3rd Request_________ CUM Rec’d:_________

State of Arizona

Department of Education

Office of English Language Acquisition Services

Primary Home Language Other Than English (PHLOTE)

Home Language Survey

(Effective April 4, 2011)

These questions are in compliance with Arizona Administrative Code, R7-2-306(B)(1), (2)(a-c).

Responses to these statements will be used to determine whether the student will be assessed for

English Language Proficiency.

1. What is the primary language used in the home regardless of the language spoken

by the student? _____________________________________________________

2. What is the language most often spoken by the student? _______________________

3. What is the language that the student first acquired? __________________________

Student Name ______________________________________ Student ID __________________

Date of Birth _____________________________________ SAIS ID ______________________

Parent/Guardian Signature __________________________________ Date _________________

District or Charter ______Painted Pony Ranch Charter School___________________________

School ______Willow Creek Charter School ______________________

--- --- 1535 West Jefferson Street, Phoenix, Arizona 85007 – (602)542-0753 – www.azed.gov/oelas

Willow Creek Charter School

Student Computer Lab/Internet Agreement

 I will only look at or delete my own files.

 I understand that I must not bring software or disks into school without permission.

 I will only e-mail people I know, or my teacher has approved.

 I will ask for permission before opening an e-mail or an e-mail attachment sent by someone I do not know.

 I will not use Internet chat.

 I will not access material deemed inappropriate for school use including dangerous info, criminal info, and inappropriate language and violates school rules.

 If I see anything that I am unhappy with or I receive messages I do not like, I will tell a teacher immediately.

 I understand that the school may check my computer files and the internet sites I visit.

 I understand that if I deliberately break these rules, I may not be allowed to use the internet or the computers.

 I will not reveal personal contact information about myself (full name, address, phone number) when using the Internet.

 I will not agree to meet with someone they have met online without their parents/guardian’s approval and participation.

 I will not access material that has been deemed inappropriate for shool use. Inappropriate material is defined as: dangerous information, Criminal information, Information that violates school rules.

 I will not purposely damage any computers or other equipment.

I hereby release Willow Creek Charter School, its personnel, and any institutions with which it is affiliated, from any and all claims and damages of any nature arising from my child’s use of, or inability to use, the Internet system, including, but not limited to claims that may arise from the unauthorized use of the system to purchase products or services.

I give my permission to allow my child, ______________________, to use the Internet

according to the Student Internet Agreement.

Parent/Guardian Signature__________________________

Date_________

I agree to follow the rules contained in the Student Internet Agreement. I understand

that if I violate the rules my account may be terminated.

Arizona Department of Education

Arizona Residency Documentation Form

Student_____________________________________ School _____________________________ School District or Charter Holder _______________________________________________________ Parent/Legal Guardian ________________________________________________________________

As the Parent/Legal Guardian of the Student, I attest that I am a resident of the State of Arizona and submit in support of this attestation a copy of the following document that displays my name and residential address or physical description of the property where the student resides:

___ Valid Arizona driver’s license, Arizona identification card or motor vehicle registration ___ Valid U.S. passport

___ Real estate deed or mortgage documents ___ Property tax bill

___ Residential lease or rental agreement ___ Water, electric, gas, cable, or phone bill ___ Bank or credit card statement

___ W-2 wage statement ___ Payroll stub

___ Certificate of tribal enrollment or other identification issued by a recognized Indian tribe that contains an Arizona address.

___ Documentation from a state, tribal or federal government agency (Social Security Administration, Veteran’s Administration, Arizona Department of Economic Security)

___ I am currently unable to provide any of the foregoing documents. Therefore, I have provided an original affidavit signed and notarized by an Arizona resident who attests that I have established residence in Arizona with the person signing the affidavit.

_____________________________________ _________________________________ Signature of Parent/Legal Guardian Date

Willow Creek Charter School

2100 Willow Creek Road, Prescott, Arizona 86301 Phone: (928) 776-1212 Fax: (928) 776-0009 Terese Soto – Director • Jennifer L. Baker – Business Director

SCHOOL COMMUNICATION

This year, we will be using a new program to help communicate better with you on all school events.

This will include information about classroom and school wide events, as well as important WCC

updates; to ensure you have the most current information from us. We will continue to send home

letters with students with this information, however, we realize that often times, it is misplaced or

doesn’t make it home to you. Receiving it in your e-mail box ensures that you see everything.

In order to do this, we need your mail addresses to update our contact database. By giving your

e-mail to us, we

WILL NOT

provide it to anyone for marketing or any other purpose. This will

ONLY

be used

for communication about WCC and your students.

Please fill out the form below and return it to school as soon as possible. If you prefer not to provide

your e-mail to us, please indicate below.

Student name(s): Level(s): Parent Name(s)

E-mail address(es):

□

I do not wish to provide my e-mail information (provide student name/level):

______________________________________________________________________

Willow Creek Charter School

2100 Willow Creek Road Prescott, Arizona 86301 Phone: 928-776-1212 Fax: 928-776-0009

Terese Soto-Director

GENERAL RELEASE FORM

No child will be admitted until all the necessary forms and information have been

completed and provided to the school.

1.

Willow Creek Charter School (WCCS) may use photographs, reproductions and/or

sound recordings of my child(ren). Such use may include website, advertising and

publicity purposes.

2.

I hereby release, indemnify and hold harmless WCCS and its staff from any loss or

damage to toys, clothes or any other personal articles.

3.

I hereby warrant WCCS that I am entitled to legal custody and possession of my

child(ren), and accordingly am authorized to place my child(ren) in you care and

custody and am further authorized to sign this release form.

4.

On admission of my child(ren) to WCCS I agree to observe the policies and

procedures as set forth by the school.

5.

I am aware that WCCS’s insurance policy covers students formally enrolled and not

other children using its facilities. Therefore, if for any reason I bring to school

children other than those enrolled, and in the event they should sustain injuries on said

premises, I hereby release and absolve the school completely and totally from all

responsibility or blame for any and all such injuries and subsequent consequences

thereof if any. The above also pertains to any animals brought onto the premises.

6.

I authorize WCCS to accept telephone release authorization of my child(ren) upon

verification.

______________________________________

_____________

Parent/Guardian Signature

Date

Willow Creek Charter School

Federal agencies have been working to implement the regulations adopted by the U.S. Office of Management

and Budget since 1997, and the Department of Education is among the last to finalize adoption, making

education data consistent with the Census data and other national data sets. Specifically, the major issue the

federal government is trying to clear up is the distinction between race and ethnicity. The change will allow

individuals the opportunity to select multiple races to more fully describe their heritage. The new regulations

specify the following five race categories: American Indian or Alaska Native, Asian, Black or African

American, Native Hawaiian or Other Pacific Islander and White.

Part A must be answered first, then

Part B.

Part A:

Is this student Hispanic/Latino? (Circle only one)



No, not Hispanic/Latino



Yes, Hispanic/Latino

(a person who is 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

one or more boxes to indicate what you consider your student’s

race to be.

Part B:

What is the student’s race? (Circle 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.)



Asian

(A person having orgins in any of the original peoples of the Far East, Southeast Asia, or

the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia,

Pakistan, the Philippine 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 Islands.)



White

(A person having origins in any of the original peoples of Europe, the Middle East or

North Africa

Student name:_________________________________

Date:___________________

Parent signature:_______________________________

AzEIP Information

What is Early Intervention? Early Intervention is professionals working in partnership with parents and families of children with special needs, to support their children’s growth, development, and learning. Early Intervention happens in places where children and families live, learn, and play; the families’ natural environments.

What is the Arizona Early Intervention Program? The Arizona Early Intervention Program, also known as AzEIP (pronounced Ay-zip), is a statewide system of supports and services for families of children, birth to three, with disabilities or developmental delays. The AzEIP system is collaboration of activities by the following State Agencies:

Department of Economic Security (DES)

DES/Arizona Early Intervention Program (AzEIP) DES/Division of Developmental Disabilities (DDD) Arizona Department of Health Services (ADHS)

Arizona State Schools for the Deaf and the Blind (ASDB) Arizona Department of Education (ADE)

Arizona Health Care Cost Containment System (AHCCCS)

Why is Early Intervention important? Research tells us that the first three years of a child’s life are critical years for learning. Early care and education have a long-lasting impact on how children develop. During a child’s first three years, it is important to focus on a child’s developmental needs and take advantage of your child’s natural ability to learn.

What happens when my child is referred to AzEIP? When your child is referred to AzEIP, your family is contacted and given information about early intervention services and eligibility. If your family is

interested in AzEIP, arrangements are made to meet at a time and place convenient for your family, in order to begin the initial planning process (IPP). The IPP process includes assessment, eligibility

determination, and, for eligible children, the development of an Individualized Family Service Plan (IFSP). During visits with the family, information about your child's development, health, and medical history is gathered, and the family's concerns, interests, and priorities are explored. Information may be gathered by reviewing existing records, observation, and/or formal evaluation measures.

If your child is eligible for the early intervention program, family members, a Service Coordinator,

individuals involved in the assessment process, and others you, the family, may wish to include, work as a team to develop desired outcomes related to your child's development. These outcomes are the

foundation of the Individualized Family Service Plan.The team members share information and resources, and identify strategies, activities, supports, and services related to these outcomes.

Your family may stay enrolled in AzEIP until your child turns three years of age or your child no longer needs

early intervention. As your child nears two and a half years of age, your Service Coordinator will help you

determine the next steps for your child. These steps may include a preschool program for children with special

needs offered by your local school district, a Head Start program, or a local childcare center.

CHILD FIND FOR WILLOW CREEK CHARTER Policy assures that:

A, All children with disabilities, including those attending private schools, who are in need of special education and related services shall be identified, located and evaluated

0300.124

B. A practical method shall be developed and implemented to determine which children are currently receiving needed special education and related services (§300,125).4'

C. This policy applies to highly mobile children with disabilities and children who are suspected of being children with disabilities under 000.7 and in need of special education, even though they are advancing from grade to grade (§300,125).

Procedures include, but are not limited to:

1, The agency will maintain documentation of the public awareness efforts to inform the public and parents within their jurisdiction, including private and religious schools, of the availability of special education services (§300.125 and AAC R7-2-401).

2. Screening activities will be implemented for all newly enrolled students and those transferring without sufficient records.

3, The screening will be completed within 45 days of enrollment.

4. The screening will include consideration of academic or cognitive, vision, hearing, communication, adaptive, emotional and psychomotor domains (AAC R7-2-401(D)(6)()).

5. The public agency will maintain documentation and annually report the number of children with disabilities within

each

disability category that have been identified, located and evaluated (§300,125). The collection and use of data to meet these requirements are subject to the confidentiality requirements of §§300.560 and 300.577.

PP 2: Child Find

6. For children and youth enrolled in private or religious schools, the public agency will consult annually with those schools to determine the number of students identified as eligible for special education and related services regardless of whether they are receiving services (§300.454).

7. Children participating in early intervention services who are expected to participate in preschool programs for children with disabilities will be assured a smooth and effective transition including:

a. transition conferences will be arranged for children between the ages of 2 years, 6 months and 2 years, 9 months;

b, by a child's third birthday, an IEP or fFSP will be developed and implemented to ensure FAPE (§300.132); and

c, for children who turn 3 years of age during the summer, the IEP team will determine the date for initiation of services including eligibility for extended school year services (§300.121 and AAC R7-2-401(c)).

8. The public agency will refer children suspected of having disabilities aged birth through two years to the Arizona Early Intervention Program (AzEIP) for evaluation and, if appropriate, services. It is the Willow Creek Charter School’s responsibility to inform the general public and all parents of students enrolled in our school of our responsibility to make available special education services for students with disabilities and how to access those services. In addition we have a responsibility to provide information

regarding early intervention services for children birth through 2 years of age. We are responsible for identifying, locating, and evaluating all children with disabilities within our school and for making appropriate

referrals to: (1) Arizona Early Intervention Program (AzEIP) for children bith through 2 yearsof age for evaluation and services if needed; and (2) School district of residence for children aged 3 through 5 for evaluation and services needed.

We are also responsible for providing a free and appropriate public education (FAPE) which includes special education and related

services for students with disabilities at public expense, under public supervision and direction and without charge to the parents. For all new students to the school, the classroom teacher will complete screening activities within 45 days of enrollment. The teacher

will look at the child’s ability in the areas of academics, vision, hearing, communication, social/emotional and motor skills. If any concerns are noted the child may be referred for additional help.

Annual Notification to Parents Regarding Confidentiality of Student Education Records and

School Directory information

Confidentiality of education records is a right of public school students and their parents. This right is Provided for by two federal laws, the Individuals with Disabilities Education Act (IDEA), and the Family Education Rights and Privacy Act (Ferpa). Under these laws, “education records” means those records That are: (1) directly related to a student; and (2) maintained by an educational agency or institution or by a party acting for the agency or institution. Of Course, education records are maintained on every child enrolled in a public school. The types of information gathered and maintained includes, but is not limited to: the student’s and parents’ names, address and telephone number; the student’s date and place of birth, date of enrollment in the school, records from previous schools attended, attendance record, subjects taken, grades, school activities, assessment results, number of credits earned, immunization records, disciplinary records,

If any, correspondence from parents, and child find and other screening results, including hearing and vision screening results.

In addition, for children with disabilities, education records could include, among other things, evaluation And testing materials, medical and health information, each annual Individualized Education Program (IEP), notices to parents, notes regarding IEP meetings, parental consent documents, information provided by parents, progress reports, assessment results, materials related to disciplinary actions, and mediation agreements.

The information is gathered from a number of sources including the student’s parents and staff of the school of attendance. Also, with parental permission, information may be gathered from additional sources including doctors and other health care providers.

This information is collected to assure proper identification of a student and the student’s parents and the maintenance of accurate records of the student’s progress and activities in school. For children with di8sabilities, additional information is collected in order to assure the child is identified, evaluated, and provided a Free Appropriated Public Education in accordance with state and federal special education laws.

Each agency participating under Part B or IDEA must assure that at all stages of gathering, storing, retaining and disclosing education records to third parties that it complies with the federal confidentiality laws. In addition, the destruction of any education records of a child with a disability must be in accordance with IDEA regulatory requirements.

The federal Family Policy Compliance Office of the U.S. Department of Education has provided the following notice of parent’s right under FERPA. In accordance with IDEA, the rights of the parents regarding education records are transferred to the student at age 18.

The Family Educational Rights and Privacy Act (FERPA) affords parents and students over 18 years of age (“eligible”) certain rights with respect to the student’s education records. They are:

(1) The right to inspect and review the student’s education records within 45 days of the day the school receives a request for access.

Parents or eligible students should submit to the school principal ( or appropriate school official) a written request that identifies the record (s) they wish to inspect. The principal will make arrangements for access and notify the parent or eligible student of the time and place where the records may be inspected.

(2) The right to request the amendment of the student’s education records that the parent or eligible student believe are inaccurate or misleading.

Parents or eligible students may ask a school district to amend a record that they believe is inaccurate or misleading. They should write the school principal, clearly identify the part of the record they want changed, and specify why it is inaccurate of misleading.

If the school decides not to amend the record as requested by the parent or eligible student, the school will notify the parent or eligible student of the decision and advise them of their right to a hearing regarding the request for

amendment. Additional information regarding the hearing procedures will by provided to the parent or eligible student when notified of the right to a hearing.

(3) The right to consent to disclosures of personally identifiable information contained in the student’s education records, except to the extent that FERPA authorizes disclosure without consent.

One exception which permits disclosure without consent is disclosure to school officials with legitimate educational interests. A school official is a person employed by the school as an Administrator, supervisor, instructor, or support staff member (including health or medical staff and law enforcement unit personnel); a person serving on the school board; a person or company with whom the school has contracted to perform a special task (such as an attorney, auditor, medical consultant, or therapist); or a parent or student serving on an official committee, such as a disciplinary or grievance committee, or assisting another school official in performing his or her tasks.

A school official has a legitimate educational interest if the official needs to review an education record in order to fulfill his or her professional responsibility.

Upon request, a school may disclose education records, without consent, to officials of another school district in which a student seeks or intends to enroll, if the school states in its annual notification of FERPA rights that it forwards records on request.

(4) The right to file a complaint with the U.S. Department of Education concerning alleged failures by a school to comply with the requirements of FERPA. The name and address of the office that Administers FERPA is. Family Policy Compliance Office

U.S. Department of Education 400 Maryland Avenue SW Washington, D.C. 20202 202-260-3887 Voice 1-800-877-8339 TDD

A school may designate information in education records as “directory information” and may disclose it without parent consent, unless noticed that the school is not to disclose the information without consent. The law defines “directory information” as follows:

The student’s name, address, telephone listing, date and place of birth, major field of study, participation in officially recognized activities and sports, weight and height of members of athletic teams, dates of attendance, degrees and awards received, and the most recent previous educational agency or institution attended by the student.