STUDENT’S PRINTED NAME
__________________________________
Thank you for your interest in Pivot Charter School! To ensure that you provide us with all of the Information we need to begin processing your application, we ask that you refer to this checklist.
__ Student Registration form __Income Survey
__Caregiver Authorization Affidavit __Signed No Child Left Behind form
(Required if you are not the legal parent/guardian)
__Authorization for Release of records form __ Emergency Contact Information __List of required documents (Not included in packet; student/ parent must obtain from other sources, including the previous school district.)
•
Proof of guardianship, if you are not the legal parent or guardian.
•
Transcript with year ending grades, progress report, or report card.
•
Proof of Residence-A CURRENT utility bill, rental/mortgage agreement or other proof of
residency.
Mail or Fax the application and requested documents to our office at:
PIVOT CHARTER SCHOOL
FT. LAUDERDALE, BROWARD
COUNTY
8129 North Pine Island Road
Tamarac, FL 33321
Phone Number: 954-720-3001
Fax: 954-722-5579
PIVOT CHARTER SCHOOL
TAMPA, HILLSBOROUGH COUNTY
3020 South Falkenburg Road
Riverview, FL 33578
Phone Number: 813-626-6724
Fax: 813-622-6712
PIVOT CHARTER SCHOOL
FT. MYERS, LEE COUNTY
2675 Winkler Ave. Suite 200
Fort Myers, FL 33901
Phone Number: 239-243-8266
Fax: 239-686-5474
954-722-5578
STUDENT REGISTRATION FORM
I am applying to (check one):
Pivot Ft. Lauderdale
Pivot Tampa
Pivot Ft. Myers
Student
Grade
6
7
8 8
9
9 10
11
12
School Year for Registration:
Date of Enrollment:
Student Identification Numbers:
SSN:
System Number:
Student Name:
Last, First, M.I.- Date of Birth:Address:
Apt.#:
City:
State
Zip:
Home Phone:
Other Phone:
Gender:
Male
Female
Primary Home Language:
Racial/Ethnic Category (Please select only one):
White/Non-Hispanic Asian Pacific Islander Hispanic Alaskan Native Black/Non-Hispanic American Indian Other if “Other”, please specify:
Student Programs/Tests/Discipline
Has the student ever been retained in a grade? NO YES if YES, list the grade(s)
Does the student require remedial instruction or tutoring? NO YES if YES, in which subject(s)? Is the student receiving/has the student received Exceptional Student Education services? YES NO
If YES, are they currently enrolled in a program and what services do they receive?
Is the student receiving/has the student received Free/Reduced school meals?
YES
NO
Has the student ever taken Advanced Placement or Dual Enrollment courses?
YES
NO
Has the student ever taken the PSAT, SAT, or ACT?
YES
NO
If YES, what exam(s)? Exam Score(s)? :
Has the student ever been placed on probation, suspended, or expelled from a school?
YES NOIF yes, please explain:
Current School of Attendance : Grade:
ADDRESS: City:
State: Zip: School Phone No.:
INCOME SURVEY
FREE AND REDUCED-PRICED SCHOOL MEALS FAMILY APPLICATION
PART 1. ALL HOUSEHOLD MEMBERS Name of all household members (first, Middle Initial ,Last)
Name of school for each child/or indicate “NA” if child is not in school
Check if a foster child (legal responsibility of welfare agency or court)
*if all children listed below are foster children, skip to Part 5 to sign this form.
Check if NO Income
PART 2. BENEFITS
IF ANY MEMBER OF YOUR HOUSEHOLD RECEIVES (STATE SNAP),(FDPIR) or (State TANF Cash Assistance), PROVIDE THE NAME OF CASE NUMBER FOR THE PERSON WHO RECEIVES BENEFITS AND SKIP TO PART 5. IF NO ONE RECEIVES THESE BENEFITS, SKIP TO PART 3.
NAME:__________________________________________CASE NUMBER:_______________________________________
PART 3. IF ANY CHILD YOU ARE APLYING FOR IS HOMELESS, MIGRANT, OR A RUNAWAY CHECK THE APPROPRIATE BOX AND CALL Deputy Superintendent- (954) 463-9995 HOMELESS MIGRANT RUNAWAY
Dawne Gullatt, Ed. S., MSW (813)273-7282
PART 4. TOTAL HOUSEHOLD GROSS INCOME. You must tell us how much and how often.
1. NAME
(LIST ONLY HOUSEHOLD MEMBERS WITH INCOME)
2. GROSS INCOME AND HOW OFTEN IT WAS RECEIVED Earning From Work before deductions Welfare,child Support, alimony Pension, retirement, Social Security, SSI, VA benefits
All other Income
(EXAMPLE) JANE SMITH $199.99/Weekly $149.99/every other Week $99.99/Monthly $50.00/monthly
PART 5. SIGNATURE AND LAST FOUR DIGITS OF SOCIAL SECURITY NUMBERS (ADULT MUST SIGN)
An adult household member must sign the application. If part 4 is completed, the adult signing the forms also must list the last four digits of his or her Social Security Number or mark the “I do not have a Social Security Number” box. (See Privacy Act Statement on the back of this page.)
I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get federal funds based on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted.
Sign here:_________________________________________ Print Name:________________________________ Date:_________________________
Address:__________________________________________________ Phone Number:_____________________ City:________________________________ State:___________________ Zip Code:________________________ Last four digits of Social Security Number: ***-**-__ __ __ __ I do not have a Social Security Number PART 6.CHILDREN’S ETHNIC AND RACIAL IDENTITIES (OPTIONAL)
Choose one ethnicity: Hispanic/Latino Not Hispanic/Latino
Choose one or more (regardless of ethnicity)
Asian American Indian or Alaska Native Black or African American White Native Hawaiian or other Pacific Islander
DO NOT FILL OUT THIS PART. THIS IS FOR SCHOOL USE ONLY.
Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice a Month x 24, Monthly X 12
Total Income:_______ Per: Week, Every 2 Weeks, Twice A Month, Month, Year Household size:______
Categorical Eligibility:______ Date Withdrawn:______ Eligibility: Free _____ Reduced_______ Denied_______ Reason:___________________________________________________________________________________ Temporary: Free ______ Reduced________ Time Period______________(expires after____days)
Your children may qualify for free
or reduced-price meals if your
household income falls at or
below the limits on this chart.
FEDERAL ELIGIBILITY INCOME CHART for School Year 2014-2015
Household Size Yearly Monthly Weekly
1 21,590 1,800 416 2 29,101 2,426 560 3 36,612 3,051 705 4 44,123 3,677 849 5 51,634 4,303 993 6 59,145 4,929 1,138 7 66,656 5,555 1,282 8 74,167 6,181 1,427
Each additional person: 7,511 626 145
Privacy Act Statement: This explains how we will use the information you give us.
The Richard B. Russell National School Lunch Act requires the information on this application. You do
not have to give the information, but if you do not, we cannot approve your child for free or
reduced-price meals. You must include the last four digits of the social security number of the adult household
member who signs the application. The last four digits of the social security number is not required
when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program
(SNAP), Temporary Assistance for Needy Families (TANF) Program, or Food Distribution Program on
Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate
that the adult household member signing the application does not have a social security number. We
will use your information to determine if our child is eligible for free or reduce-price meals, and for
administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility
information with education, health and nutrition programs to help them evaluate, fund or determine
benefit for their programs, auditor for program review, and law enforcement officials to help them look
into violations of program rules.
Nondiscrimination Statement: This explains what to do if you believe you have been treated unfairly. “In
accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited
from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a
complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue,
SW, Washington, D.C. 20250-9410 or call toll free (866)632-9992
STUDENT REGISTRATION FORM PIVOT CHARTER SCHOOL- FLORIDA
FAMILY INFORMATION
Name of Parent/Guardian:
Relationship to Student
Parent
Guardian
Other
(specify below)
Address:
City:
State:
Zip:
Phone Numbers
Home:
Work:
Cell:
Email Address:
Name of Parent/Guardian:
Relationship to Student
Parent
Guardian
Other
(specify below)
Address:
City:
State:
Zip:
Phone Numbers
Home:
Work:
Cell:
Email Address:
Parent and Or Guardians Highest Level of Education Completed
HS
DIPLOMA/GED
TRAINING
MILITARY
2 YEAR
DEGREE
4 YEAR
DEGREE
MOTHER
FATHER
GUARDIAN
OTHER
Student School Age Siblings
Name
Age
School
Name
Age
School
PIVOT TRANSPORTATION
In order to be accommodate the busing needs, please check the appropriate box if
your student(s) would like to take advantage of the busing system and include your address.
Yes, my student (s) will be using the future busing system.
Our address is___________________________________________________________
Street Apt #: City
Zip
NO, my student(s) will have alternate means of transportation.
To accommodate students needing transportation, Pivot Charter School will pay for a student city bus
pass through Broward County Transit.
YES, my student(s) will need a city bus pass.
CAREGIVER AUTHORIZATION DOCUMENTATION
REQUIRED IF YOU ARE NOT THE PARENT OR LEGAL GUARDIANInstructions: Completion of items 1-4 and the signing of the affidavit are sufficient to authorize
enrollment of a minor in school and authorize school-related medical care. Completion of item 5-8 is
additionally required to authorize any other medical care. Print Clearly.
The minor named below lives in my house and I am 18 years of age or older.
1. Name of Minor
2. Minor’s date of birth
3. My name (adult giving authorization)
4. My home address:
5.
I am a grandparent, aunt, uncle, or other qualified relative of the minor.
6. Check one or both (for example, if one parent was advised and the other cannot be
located):
I have advised the parent(s) or other person(s) having legal custody of the minor of my
intent to authorize medical care, and have received no objection.
I am unable to contact the parent(s) or other person(s) having legal custody of the minor at
this time to notify them of my intended authorization.
7. My date of birth:
8. My driver’s license or identification card number:
Warning: Do not sign this form if any of the statements above are incorrect or you will be committing
a crime punishable by a fine, imprisonment, or both.
I declare under penalty of perjury under the laws of the State of Florida that the foregoing is true and
correct.
Printed Name:__________________________________________________________________
Signature:_____________________________________________________________________
Date:_________________________________________________________________________
PARENT NOTIFICATION
Pursuant to the federal No Child Left Behind Act, P.I.. 1.07-110 (Title Ix,sec.9528), Pivot Charter School,
must disclose to military recruiters and institutions of higher learning, upon request, the names,
addresses, and telephone numbers of high school students.
The Pivot Charter School must also notify parents/guardians of their right and the right of the
student to request that the district not release such information without prior written consent.
Parent/Guardian wishing to exercise their option to withhold their consent to the release of their
student’s information to the military recruiters and institutions of higher learning must sign the form
below and return to Pivot Charter School. If you do not return this form, Pivot Charter School, will
consider this affirmation that you consent to your student’s directory information being released
if requested by military and/or institution of higher learning.
Reservation of Consent for the Release of Certain Student
Information Under the No Child Left Behind Act
Please do not release to military recruiters and / or institutions of higher learning, the name, address,
and telephone number of:
AUTHORIZATION FOR THE RELEASE OF RECORDS
Cumulative Records/Transcript Request/ Special Education RecordsIn accordance with the Family Educational Rights and Privacy Act of 1974 and Florida State Law, please release to the school named below all records, including:
Cumulative and or Permanent Academic/Health Records Transcripts of Completed Work including Grades to Date Scores and Related ELL information
Any Other Educational Information Immunization Records
Test Scores IEP/504 Records
NOTE: A separate request from our special education department will follow this request, if applicable. To be completed by the parent/guardian:
Student Name:__________________________________________________________________ Birth Date:____________________________ Grade:__________________________________ Parent/Guardian Signature:_______________________________________________________ Name of Last School Attended:_____________________________________________________ Address of Last School Attended:___________________________________________________ City:_______________________________ State:______________________ Zip:____________ Dates Attended:________________________________________________________________
Receiving Registrar: Please complete the following in response to education records, sign, date and return by mail.
◊
We do not have the records you have requested in our files◊
We have not been able to locate the requested files but our records indicate this student did receive special education services.◊
After reviewing or records, it is determined that the above named student has not received special education services nor has been identified as being eligible for special education services.Please check the appropriate box(s):
◊
Expulsion Dates: from______________ to _______________◊
Expulsion Pending◊
E.C. # 49079 Advise Teacher Regarding Violent Pupil◊
I.E.P 504◊
Student is/has been recently suspended* REGISTRAR-PLEASE FORWARD THE STUDENT CUMULATIVE RECORDS TO:
PIVOT CHARTER SCHOOL-FT.LAUDERDALE 8129 N. PINE ISLAND ROAD
TAMARAC, FLORIDA 33321 MAIN:(954)720-3001 FAX:(954) 722-5578
PIVOT CHARTER SCHOOL-FT.MYERS 2675 WINKLER AVE., SUITE 200 FORT MYERS, FL 33901 MAIN:(239)243-8266 FAX:(239)689-5474
PIVOT CHARTER SCHOOL-TAMPA 3020 SOUTH FALKENBURG RD. RIVERVIEW, FL 33578
EMERGENCY CONTACT INFORMATION
Student Name:
Please complete all information requested below.
In case of Emergency the first contact attempt will be the parent/guardian. If the parent/guardian
cannot be reached, we will attempt to contact the additional names listed below.
Contact Name Relationship to student Phone Number (s) Contact Name Relationship to student Phone Number (s) Contact Name Relationship to student Phone Number (s) Physician Name Phone Number Physician Name Phone Number
Allergies and Medical Issues
Epileptic Diabetic Type 1 Diabetic Type 2 Nut Allergy Bee/Wasp Stings Heart Condition Allergies Others
