Enrollment Forms Packet (EFP)
Iowa Virtual Academy Enrollment Processing Center 2300 Corporate Park Drive Suite 200
Herndon, VA 20171 Ph. 855.718.7722 Fx. 855.281.4012 www.k12.com/iava
Please review the information below. Based on your student(s) grade and applicable circumstances, you are required to submit documenta-tion in order to complete this step in the enrollment process. You can fax, scan and email, or mail the required paperwork .
Important Note: Please send copies, do not mail the original documents
Fax (preferred): Scan and Email: Mail:
1-855-281-4012 [email protected] Iowa Virtual Academy
Enrollment Processing Center
2300 Corporate Park Drive
Suite 200
Herndon, VA 20171
Required For? Item Description Provided by?
Required for all Students
Open Enrollment Application
Please complete form and submit. (Directions for completing this form are included in the packet)
Provided in this packet
Proof of Age Official Birth Certificate (not the hospital issued certificate) Provided by you
Proof of Residency
A copy of the following: Current (dated within the past 6 months) Utility bill OR Tax statement OR Mortgage/Rental Agreement statement showing physical
address. Provided by you
Immunization
Record Current Immunization Record. Provided by you
Report Card The most recent Report Card. Provided by you
Home Language
Survey Please complete all questions and submit. Provided in this packet
Health Form Please complete this form and submit. Provided in this packet
Release of Records
By filling out this form, you are giving our school permission to request your student’s official records from their previous school after the approval process. If your child was Homeschooled please indicate it on the form, fill out the top portion and sign it.
Provided in this packet
Required for Kin-dergarten and first time public school students only
Dental Screening Please complete this form and submit. Provided in this packet
Required for Stu-dents that have an IEP or other Special Education needs
IEP A copy of your student’s current IEP (Individualized Education Plan). Because the IEP expires yearly, please submit the current IEP. Provided by you Evaluation Team
Report The Evaluation Team Report is valid for 3 years. If you do not have a copy of your student’s ETR, please obtain a copy from your student’s current school. Provided by you Required for
stu-dents that have a 504 plan
504
Open Enrollment Application
Definitions/Directions
The deadline for filing an open enrollment application for the 2013-2014 school year is March 1, 2013. If the student will be entering school for the first time as a kindergarten student, the deadline is
September 1, 2013.
Open Enrollment applications must be submitted to the resident and to the receiving districts. Students that open enroll in Grades 9-12, shall not be eligible to participate in varsity contests and competitions during the first ninety (90) school days of transfer. Please contact the Iowa Girls High School Athletic Union at (515) 288-9741 or the Iowa High School Athletic Association at (515) 432-2011 for questions regarding eligibility.
The following guidelines are applicable to the 2013-2014 Open Enrollment Application. Continuation – Students in a family moving from District A to District B after March qualify for open enrollment and are not subject to provisions of a diversity plan or eligibility for extra-curricular activities.
Diversity Plan and Sibling Preference-The following districts have a diversity plan on file with the Department of Education: Davenport, Des Moines, Postville, Waterloo, West Liberty.
If an applicant lives in one of the districts with a diversity plan and has a sibling open enrolled to another district, the applicant qualifies for “sibling preference”: the student is given preference to open enroll, but does not automatically qualify for approval. The name(s) of the sibling (s) and the district to which they are open enrolled is needed to verify enrollment.
Home School (Competent Private Instruction) CPI students may open enroll. The deadline for CPI applications is March 1. Dual enrollment for academics, extra-curricular, and Home School Assistance Programs are available to students open enrolling from one district to another. Students may open enroll for home school (CPI) without dual enrollment.
Good Cause
In order to qualify for open enrollment after the March 1 deadline, the applicant must meet one of the conditions specified in # 12 on the application.
A. A change in resident district is required for the first five circumstances. B. A foreign exchange student qualifies for open enrollment.
C. If a district has negotiated with another district to whole grade share or to reorganize and the negotiations fail after March 1, students from the affected grades qualify for open enrollment. D. If a school accreditation is revoked or surrendered or if a school is closed after March 1,
students enrolled in the school qualify for open enrollment. This does not apply to the closing of a building within a district.
E. Pervasive Harassment - The resident district determines if the applicant qualifies under the criteria of pervasive harassment. The following guidelines are used to determine if an
applicant qualifies under the "good cause" provision. A parent or guardian who files an application for open enrollment after the March 1 deadline and alleges repeated acts of
Open Enrollment Application-Directions/Definitions
2013-2014 School Year
harassment is entitled to a hearing before the resident school board to try to prove that the application should be granted.
1. The harassment must have occurred after March 1 or the student or parent is able to demonstrate that the extent of the harassment could not have been known until after March 1.
2. The harassment must be specific electronic, written, verbal, or physical acts or conduct toward the student which created an objectively hostile school environment that meets one or more of the following conditions:
a. Places the student in reasonable fear of harm to the student's person or property. b. Has a substantially detrimental effect on the student's physical or mental health. c. Has the effect of substantially interfering with a student's academic performance. d. Has the effect of substantially interfering with the student's ability to participate in or to
benefit from the services, activities, or privileges provided by a school.
3. The evidence must show that the harassment is likely to continue despite the efforts of school officials to resolve the situation.
4. Changing the student’s school district will alleviate the situation. In re Hannah T., 25 D.o.E. App. Dec. 26 (2007).
F. Severe Health Need - An applicant may qualify under the severe health need provision if one of the following exists. An official in the resident district determines if the applicant qualifies under the criteria of severe health need:
1. The serious health condition of the child is one that has been diagnosed by an appropriate health care provider, and the diagnosis has been provided to the district of residence. 2. The serious health condition is neither short-term nor temporary.
3. The district has been provided with the specifics of the child’s health needs caused by the serious health condition and knows, or should know, what specific steps its staff must take to meet the child’s needs.
4. School officials, upon notification of the serious health condition and the steps to be taken to meet the child’s needs must have failed to implement such steps or, despite the
district’s efforts, its implementation of the steps was unsuccessful.
5. A reasonable person could not have known before March 1 that the district could not, or would not, adequately address the child’s health needs.
6. It can be reasonably anticipated that a change in the child’s school district will improve the situation.
Transportation assistance- Parents are responsible for transporting children open enrolled to another district. This applies to all students, including those with an IEP. As a general rule, if the need for transportation as a related service is stated in the IEP, the parent is responsible for this obligation under open enrollment.If a child open enrolls to a district that is contiguous (borders) to the home district, and the parents’ income meets economic eligibility requirements, the family may receive a stipend for transportation or be provided transportation by the district. The stipend for 2011-2012 was $454.00 annually per student up to three (3) elementary and one (1) secondary (Grades 9-12) student. Income verification must be provided to the resident district.
1
Deadline: March 1, 2013 September 1, 2013 for Kindergarten A copy of the application must be sent to the sending and receiving districts.
Name of Student ______________________________ Date of Birth: ______________ 1. Grade Level for 2013-2014 _______ 2. Female _____ Male _____ 3. Parent/Guardian_____________________________________________________
Telephone _________________________________________________________ Note: It is helpful to have more than one number. H=home W=work C=cell
Address_______________________________________________________________ Street/Box City Zip County 4. Resident District ________________________Attendance Center_____________ 5. District Requested _______________________Attendance Center* _____________
*Request does not guarantee placement
6. Is this application a request to continue education in the former district of residence following a move to a new district? ________ Yes _________ No
7. If the resident district has a diversity plan, please indicate if the applicant has a sibling currently under open enrollment? If yes, please provide the following:
Sibling:
Name_____________________________________________________ District/School open enrolled __________________________________ 8. The student will be enrolled in the following (check all that apply):
Regular Education _____ Special Education _____
Home School (CPI) _____ Home School Assistance Program _____ Dual Enrollment – Academic _____ Dual Enrollment – Activity Program _____ 9. Is your child currently eligible for receiving special education services?
Yes _____ No _____
10. Is your child currently being evaluated for special education services? Yes _____ No _____
11. Is the student currently under suspension or expulsion from school? ____ No ____ Yes
If yes, when will the suspension / expulsion be complete? _________________________________ 12. This section should be completed IF the application is being filed after March 1.
Qualifications for Good Cause Date of Change a) Change in district of residence due to: family move, change in _________________
Marital status, foster care, adoption, or treatment program
b) Participation in foreign exchange program _________________ c) Failure of negotiations for reorganization or whole grade sharing ________________
Open Enrollment Application
2013-2014 School Year
2
d) Loss of accreditation or revocation of a private or charter school ________________ e) Pervasive harassment or severe health. Briefly describe events
occurring after March 1 or provide the name of a district employee
familiar with the student. ___________________________________________________ _______________________________________________________________________ 13. Request for transportation assistance. Yes ______ No _____
If yes, attach proof of income to application and number in household.
I certify the above information is true and I have sent a copy of this form to my resident district and to the district I want my child to attend.
Signature of Parent or Guardian Date
CAUTION: Knowingly providing false information on this form will invalidate the application.
Receiving District
The receiving district has the authority to take action on all applications (before or after March 1) except: a) Those alleging harassment or severe health need condition that cannot be accommodated in
resident district.
b) Resident district had a diversity plan.
Date application was received: ____________________________________
Approved: ________________________________________________________________________ Date Signature of Superintendent
Denied _________________________________________________________________________ Date of School Board Action Signature of Superintendent
If denied, indicate reason:
_____ Request was not filed by March 1 and does not meet good cause. _____ Insufficient classroom space
_____ Student under suspension or expulsion
_____ Appropriate special education program is not available.
_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ ___ Resident District
Resident district is taking action on this application because of the following:
_____ Resident district has a diversity plan on file with Department of Education. _____ Student alleges pervasive harassment that began or escalated after March 1. _____ Student has a severe health condition that began or escalated after March 1. Date application was received: ______________________________________________________ Approved: ______________________________________________________________________ Date Signature of Superintendent
Denied: ________________________________________________________________________ Date of School Board Action Signature of Superintendent
If denied, indicate reason:
_____ Does not meet diversity plan criteria
_____ Does not meet criteria for pervasive harassment _____ Does not meet criteria for severe health condition
2300 Corporate Park Dr. Ste. 200, Herndon, VA 20171 Ph. 855.718.7722 Fx. 855.281.4012
Health History Form
In case of an emergency, and the parents/guardian or other contact Person(s) listed cannot be reached, I authorize school officials to take whatever action is deemed necessary in their judgment for the health of my child. This includes
transport of the child to the nearest physician or hospital. I will not hold the school district financially responsible for the emergency care and transportation of the child. I grant permission to share the below medical information with other school personnel who may be responsible for my child at times throughout the day such as: bus driver, secretary, teacher associates etc.
Acetaminophen (Tylenol) for headache and fever
Ibuprofen (Advil, Motrin) for muscle aches and pains, cramps, sinus pain
Maalox (or comparable nonprescription antacid) in liquid or tablet form for stomach upset Laratadine (Claritin) for allergies and sinus
Clotrimazole (as an antifungal for skin itch and rash
Ocean Nose Spray (or generic saline nasal spray) for stuffy nose or nasal dryness Natural tears (or any saline eye drops) for eye dryness and/or itching
Visine Allergy Eye Drops for itching eyes
Cough Syrup (non-alcohol based, such as Robitussin) for dry coughs
Calamine or Caladryl Lotion (or generic) for itchy rash (do not apply around eye) Benadryl (Diphenhydramine HCL) for allergy symptoms
Topical antibiotic ointment for minor cuts and scrapes
Topical Hydrocortisone Cream for minor skin irritation and rashes (not on face) Benzocaine Sting Wipes for insect bites and stings
Oragel (or generic) for temporary relief of mild toothache Please Print
Student’s Name: _____________________________________ Date of Birth: ___________ Grade: ____________
Allergies: YES No If yes, Allergic to_____________________________________________________________
Medications: ______________________________________________________________________________________
Health Problems (asthma, ADHD, diabetes, etc.): _________________________________________________________ _________________________________________________________________________________________________
Emergency Contact: ______________________________ Phone: _____________________ Cell: _________________
Parent/Guardian Signature Date
Iowa Department of Public Health
CERTIFICATE OF DENTAL SCREENING
This certificate is not valid unless all fields are complete. 5(7851&203/(7(')25072&+,/'¶66&+22/
Iowa Department of Public Health x Oral Health Bureau
515-281-3733 x 866-528-4020 x www.idph.state.ia.us/hpcdp/oral_health.asp
A designee of the local board of health or Iowa Department of Public Health may review this certificate for survey purposes.
7/18/2011
Student Last Name:
Student First Name: Birth Date (M/D/YYYY): Parent or Guardian Name: Telephone (home or mobile):
Street Address: City: County:
Name of Elementary or High School: Grade Level: Gender:
Male Female
Date of Dental Screening: ________________________________
Treatment Needs (check ONE only based on screening results, prior to treatment services provided): No Obvious Problems ± WKHFKLOG¶VKDUGDQGVRIWWLVVXHVDSSHDUWREHYLVXDOO\KHDOWK\DQGWKHUH
is no apparent reason for the child to be seen before the next routine dental checkup.
Requires Dental Care ± tooth decay¹ or a white spot lesion² is suspected in one or more teeth, or gum infection³ is suspected.
Requires Urgent Dental Care ± obvious tooth decay¹ is present in one or more teeth, there is evidence of injury or severe infection, or the child is experiencing pain.
Screening Provider (check ONE only):
DDS/DMD RDH MD/DO PA RN/ARNP (High school screen must be provided byDDS/DMD or RDH)
Provider Name: (please print) Phone:
Provider Business Address: Signature and Credentials
of Provider or Recorder*: Date:
*Recorder: An authorized provider (DDS/DMD, RDH, MD/DO, PA, or RN/ARNP) may transfer information onto this form from another health document. The other health document should be attached to this form.
A screening does not replace an exam by a dentist.
Children should have a complete examination by a dentist at least once a year. 5(7851&203/(7(')25072&+,/'¶66&+22/
¹ Tooth decay: A visible cavity or hole in a tooth with brown or black coloration, or a retained root.
² White spot lesion: A demineralized area of a tooth, usually appearing as a chalky, white spot or white line near the gumline. A white spot lesion is considered an early indicator of tooth decay, especially in primary (baby) teeth. ³ Gum infection: Gum (gingival) tissue is red, bleeding, or swollen.
Student Information (please print)
Home Language Survey
Date: School: Grade:
Student’s Legal Name:
First Name Middle Initial Last Name
Parent or Guardian’s Name:
First Name Middle Initial Last Name
Address:
Street City State Zip Code
Phone Number:
Home Work Cell
1. Child’s date of birth
Was your child born in the United States? YES o NO
If yes, in which state?
If no, in what other country? Date child entered in the United States: 2. Has your child attended any school in the United States for any three years during their lifetime? o YES o NO
If yes, please provide school name(s), state, and dates attended:
Name of School: State: Dates Attended:
Name of School: State: Dates Attended:
Name of School: State: Dates Attended:
3. What is the language most frequently spoken at home?
4. If available, in what language would you prefer to receive communication from the school? 5. Please check if your child is: A. oNative American Indian B. oAlaska Native C. oNative Pacific Islander D. oNative U.S. Virgin Islander
6. Is your child’s first learned or home language anything other than English? oYES oNO If you responded “YES” to question 6, please answer the following questions:
In what country did your child most recently reside:
Which language did your child learn when he/she first began to talk:
Which language does your child most frequently speatk at home:
What language do you most frequently speak to your child: Father: Mother: 7. Please describe the language understood by your child. (Check Only One)
A. o Understands only the home language and no English.
B. o Understands mostly the home language and some English.
C. o Understands the home language English equally.
D. o Understands mostly English and some of the home language.
E. o Understands only English.
Parent or Guardian Signature: Date:
Parent or Guardian Name Printed: Date:
Iowa Virtual Academy Enrollment Processing Center 2300 Corporate Park Drive Suite 200
Herndon, VA 20171 Ph. 855.718.7722 Fx. 855.281.4012 www.k12.com/iava
Iowa Virtual Academy Enrollment Processing Center 2300 Corporate Park Drive Suite 200 Herndon, VA 20171 Ph. 855.718.7722 Fx. 855.281.4012 www.k12.com/iava Student Information
Student’s Full Name:
first middle last
Student’s Date of Birth: Student’s Legal Address:
street apt #
city county state zip
Home Phone:
Check below if applicable:
o Student was always previously homeschooled o Student is enrolling in Kindergarten
Name of Prior School: School’s Address:
street
city county state zip
School’s Phone: School’s Fax:
N
Name of Parent or Legal Guardian:
first last
Parent/Guardian’s Signature: Date:
Release of Student Records
Please accept this document as formal approval for the release of all official school records (including the record of transcripts, testing information, special education, health and immunization records).
Homeschooled or Never Previously Enrolled in School (Fill out only if applicable)
Prior School Information
Sign and Date below
SCHOOL OFFICIALS ONLY:
Send student records to: Iowa Virtual Academy c/o Clayton Ridge Schools P.O. Box 520
Guttenberg, IA 52052-0520
Iowa Department of Public Health Certificate of Immunization
Name Last: First: __________ ___ Middle: _____ ___________ Date of Birth: _________________ Parent/Guardian: __________________________ Address: _____________________________________________________ Phone: (____)_________________ I certify that the above named applicant has a record of age-appropriate immunizations that meet the requirement for licensed child care or school enrollment.
Signature: __________________________________________________________________ Date: ______________________
Physician, Physician Assistant, Nurse, or Certified Medical Assistant
A representative of the local Board of Health or Iowa Department of Public Health may review this certificate for survey purposes.
Vaccine Date Given Doctor / Clinic / Source
Rev. 12/2008
Meningococcal
MCV4/MPSV4
Hepatitis A
Rotavirus
Vaccine Date Given Doctor / Clinic / Source
Diphtheria, Tetanus, Pertussis DTaP/DTP/DT/ Td/Tdap Polio IPV/OPV Measles, Mumps, Rubella MMR Haemophilus influenzae type b Hib Hepatitis B Varicella Chicken Pox If applicant has a history of natural disease write “Immune to Varicella” Pneumococcal PCV/PPV Human Papilloma Virus HPV Other
Licensed Child Care Requirements
4 through 5 months 1 dose Diphtheria/Tetanus/Pertussis 1 dose Polio 1 dose Hib 1 dose Pneumococcal 6 through 11 months 2 doses Diphtheria/Tetanus/Pertussis 2 doses Polio 2 doses Hib 2 doses Pneumococcal 12 through 18 months 3 doses Diphtheria/Tetanus/Pertussis 2 doses Polio
2 doses Hib or 1 dose received at > 15 months of age. 3 doses Pneumococcal if received 1 or 2 doses < 12 months of age; or 2 doses if received 1 dose > 12 months of age
or has not received this vaccine before.
19 through 23 months
4 doses Diphtheria/Tetanus/Pertussis 3 doses Polio
3 doses Hib with the final dose in the series > 12 months of age, or 1 dose
received > 15 months of age.
1 dose Measles/Rubella > 12 months of age.
1 dose Varicella > 12 months of age if born on or after September 15, 1997,
or a reliable history of natural disease.
4 doses Pneumococcal; or 3 doses if received 1 or 2 doses
< 12 months of age; or 2 doses if received 1 dose > 12 months of age or has not received this vaccine before.
24 months and older
Same requirements as the 19-23 months except 4 doses Pneumococcal if received 3 doses < 12 months of age; or 3 doses if received 2 doses < 12 months of age; or 2 doses if received 1 dose < 12 months of age or received 1 dose between 12 and 23 months of age; or 1 dose if no doses had been received prior to 24 months of age.
Elementary/Secondary School Requirements
4 years of age and older
5 doses Diphtheria/Tetanus/Pertussis with at least 1 dose received > 4 years of age if born on or after September 15, 2003; or 4 doses, with 1
dose received > 4 years of age if born after September 15, 2000, but before September 15, 2003; or 3 doses, with 1 dose received
> 4 years of age if born on or before September 15, 2000.
4 doses Polio with 1 dose received > 4 years of age if born on or after September 15, 2003; or 3 doses, with 1 dose received > 4 years of age if born
on or before September 15, 2003.
2 doses Measles/Rubella; the first dose shall have been received > 12 months of age; the second dose shall have been received > 28 days after the first. 3 doses Hepatitis B if born on or after July 1, 1994.
2 doses Varicella > 12 months of age if born on or after September 15, 2003; or 1 dose received > 12 months of age if born on or after September 15,
Iowa Department of Public Health
Certificate of Immunization Exemption
Medical
Name Last: ___________________________ First: _________________________ Middle: _______________ Date of Birth: ___________________
The above named applicant qualifies for a Medical Exemption to Immunization for the following reason (select one):
In the opinion of a physician, nurse practitioner, or physician assistant the required immunizations would be injurious to the health and well-being of the applicant or any member of the applicant’s family or household. In this circumstance, the exemption may apply to a specific vaccine(s) or all vaccines. If, in the opinion of the physician, nurse practitioner, or physician assistant issuing the medical exemption, the exemption should be terminated or reviewed at a future date, an expiration date shall be recorded on the Certificate of Immunization Exemption.
Administration of the required vaccine would violate minimum interval spacing. In this circumstance, the exemption shall apply only to an applicant who has not received prior doses of exempted vaccine. An expiration date, not to exceed 60 days, and the name of the vaccine shall be recorded on the certificate.
Medical exemptions do not apply in times of emergency or epidemic as determined by the state board of health and declared by the director of public health. A Certificate of Immunization Exemption for medical reasons is valid only when signed by a physician, nurse practitioner, or physician assistant.
List vaccine(s): ____________________________________________________ Certificate Expiration Date: __________________
Signature: ________________________________________________________ Date: ____________________________________
Physician (MD or DO), Physician Assistant, Nurse Practitioner
Religious
Name Last: ___________________________ First: _________________________ Middle: _______________ Date of Birth: ___________________
A religious exemption may be granted to an applicant if immunization conflicts with a genuine and sincere religious belief. A Certificate of Immunization Exemption for religious reasons shall be signed by the applicant or, if the applicant is a minor, by the parent or guardian or legally authorized representative and shall attest that the immunization conflicts with a genuine and sincere religious belief and that the belief is in fact religious, and not based merely on philosophical, scientific, moral, personal, or medical opposition to
immunizations. The Certificate of Immunization Exemption for religious reasons is valid only when notarized. Religious exemptions do not apply in times of emergency or epidemic as determined by the state board of health and declared by the director of public health.
Signature: Date:
Applicant, Parent or Guardian
State of _______________________ County of ________________________
This instrument was acknowledged before me on ___________________________ Seal or Stamp
Date
by __________________________________________________________________
Name(s) of Person(s)
Signature of Notary Public: ______________________________________________ Title (or Rank for Military Personnel): _____________________________
