Enrollment Forms Packet (EFP)

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Enrollment Forms Packet (EFP)

Required For?

Item

Description

Provided by?

Required for all

Students

Proof of Age

Official Birth Certificate (not the hospital issued certificate) OR Baptismal Records Provided by

_you

Proof of Residency

Please sumbit two of the following items: Current utility bill, Illinois driver’s

license or State of Illinois identification card, deed, employer identification card,

MediPlan/Medicaid card, voter registration card, court documents, Illinois

Depart-ment of Public Aid card, stamped USPS change of address form, Illinois state aid

check/social security check, other identification card issued by a federal or state

agency or foreign government consulate such as the Matricula Consular.

Provided by

you

Report Card

The most recent Report Card, except for students enrolling in Kindergarten.

Provided by

_you

Immunization

Record and Medical

Form

Please have forms filled out by your students physician and submit to CVCS.

Provided in this

packet

Early Dismissal

Release

Authoriza-tion Form

This form exists so that you can authorize certain people to release your child from

school. Please note that they will be the only ones which can release your child.

Provided in this

packet

Health Insurance and

Informaiton Form

Please fill out and submit.

Provided in this

packet

Student

Transporta-tion Form

To ensure the safety of your child, CVCS requires that you confirm how your

student will be getting to and from the Learning Center each week. This

informa-tion will also be on each student’s ID card so CVCS staff knows exactly how each

student will safely leave the building.

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 is enrolling in Kindergarten or was Homeschooled please indicate it on

the form, fill out the top portion and sign it.

Provided in this

packet

Home Language

Survey

A list of Home Language Codes is also provided to use as a reference guide.

Provided in this

packet

Required for all

10 -11th Grade

Students

Unofficial

Tran-scripts

You will need to request an unofficial transcript from your student's current school,

which will show your student’s academic standing. This is required in order to

place all 10th and 11th graders. Once your student is approved, we will receive

the official transcript.

Provided by

you

Required for

student with 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 Report

The Evaluation Report is valid for 3 years. If you do not have a copy of your

_{student’s ER, you can request a copy from your student’s current school.}

Provided by

_you

Required for

students that have a

504 plan

504 Accommodation

Plan

A copy of your student’s current 504 Accommodation Plan. Because the 504

expires yearly, please submit the current 504.

Provided by

you

Please review the information below. Based on your student(s) grade and applicable circumstances, you are required to

sub-mit documentation in order to complete this step in the enrollment process.

You will need to bring these documents in person to be reviewed by a CVCS administrator, do not fax or mail these into CVCS

and make sure you bring originals for review. Our address is below:

Chicago Virtual Charter School

38 S. Peoria Street

Chicago, Il 60607

Office Hours Mon-Fri 8 AM-4PM

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Chicago Virtual Charter School Enrollment Processing Center 38 S. Peoria Street

Chicago, Il 60607 Ph. 866.467.6186 www.Chicagovcs.org

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REQUEST FOR STUDENT RECORDS

(This section to be filled out by parent):

Name of school currently holding student records: ____________________________________________________

School Phone Number: ___________________________

School Fax Number: _____________________________

Street Address: __________________________________________________________________

City, State, Zip: __________________________________________________________________

(This section to be filled out by CVCS):

Dear School Official:

Date: ______________________________

The following student has enrolled at Chicago Virtual Charter School for the 2009-2010 school year:

Name: __________________________________

ID Number: ______________________________

Date of Birth: _____________________________

Please send the following records pertaining to the aforementioned student:

Cumulative Records Card

Cumulative Folder

Medical Folder

Individualized Learning Plan (if applicable)

Special Education Records (504 or IEP, or School Based Problem Solving file)

Please forward records to:

Chicago Virtual Charter School

or

CPS Mail Run/GSR 38

Attn: Freddie Gonzalez – Registrar

38 South Peoria Street

Chicago, Illinois 60607

Should you have any questions, please contact Freddie Gonzalez, Registrar, at 312-786-9428 ext 585.

PARENTAL PERMISSION IS NO LONGER REQUIRED WHEN RECORDS ARE REQUESTED BY

AUTHORIZED SCHOOL PERSONNEL.

c/o Merit School of Music

38 South Peoria Street

Chicago, Illinois 60607

312-267-4486 Phone

312-676-3689 Fax

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Student Transportation Form

To ensure the safety of your child, CVCS requires that you confirm how your student will be getting to and from

the Learning Center each week. This information will also be on each student’s ID card so CVCS staff knows

exactly how each student will safely leave the building. Please complete the form below and turn in to Mr.

Gonzalez with your compliancy documents. Thank you in advance for your help and cooperation.

Learning Coach First Name: ______________________________________

Learning Coach Last Name: ______________________________________

Student First Name: ___________________________________________

Student Last Name: _____________________________________________

Only one box should be checked:

Please indicate how your child will be getting to and from the Learning Center each week.

Parent/guardian will drop off/pick up student at the side door of the school

Student will carpool with a friend/neighbor and will be picked-up at the side door of the school

Name of friend/neighbor: ____________________________________

Student will be picked up by a friend/neighbor and will wait in the CVCS Parent Room

Name of friend/neighbor: ____________________________________

Parent/guardian will wait in the CVCS Parent Room

Student will be taking public transportation (CTA bus or train)

c/o Merit School of Music

38 South Peoria Street

Chicago, Illinois 60607

312-267-4486 Phone

312-676-3689 Fax

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Chicago Virtual Charter School

c/o Merit School of Music

38 S Peoria St

Chicago, IL 60607

Early Dismissal Release Authorization

The following people have your authorization to release your child from school. Please note that they will be the only ones who can release your child. A valid ID must be presented at all times to the office clerk , and they must be 18 years or over.

Name:(last)_______________________________(first)__________________________Relationship:__________________

Work Phone: (____)__________________ Home Phone: (____)__________________ Cell Phone: (____)_________________

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Chicago Virtual Charter School

c/o Merit School of Music

38 S Peoria St

Chicago, IL 60637

Health Insurance and Health Information Primary Physician Information:

Doctor Name:___________________________________________ Doctor Phone:_____________________________________

Dentist Name:__________________________________________ Dentist Phone:_____________________________________

If the student is covered by Medicare, provide the Medicare number:___________________________________________________

Read and Check:

be receiving-including but not limited to: vision and hearing screenings, nursing services, speech therapy, occupational and/or physical therapy-the school district as the right to receive partial reimbursement from Medicare for those services renderedfrom Medicare for those services rendered

Please list any serious allergies, conditions, or restrictions the student has:____________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________ _________________________________________________________________________________________________________

Please list any physical or emotional disabilities the student has:_____________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

EMERGENCY RELEASE

CVCS will attempt to reach the parent/legal guardian or one of the people listed as an emergency contact but if none of these people can be reached, CVCS personnel have my permission to use discretion in securing medical aid in an emergency. IT IS UNDERSTOOD THAT NEITHER CVCS NOR THE PERSON RESPONSIBLE FOR OBTAINING THIS MEDICAL AID WILL BE RESPONSIBLE FOR THE EXPENSE INCURRED.

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Complete this Home Language Survey at the student’s initial enrollment in Chicago Public Schools.

(This form must be kept in the student’s folder.)

School:

Room:

Unit:

Area:

Student Name:

Student ID No.:

English

1. Is a language other than English spoken at home?

No

Yes

(Language)

2. Does the student speak a language other than English?

No

Yes

_(Language)

Spanish

Polish

1. ¿Se habla algún otro lenguaje que no sea ingles en el hogar?

1. Czy językiem innym niż angielski mówi się w domu?

No Sí (Lenguaje) Nie Tak (język)

2. ¿Habla el estudiante un lenguaje que no sea el inglés? 2. Czy uczeń mówi innym językiem niż angielski?

No Sí (Lenguaje) Nie Tak (język)

Chinese

Arabic

Bosnian/Croatian/Serbian

Urdu

Chicago Public Schools

Signature of Parent/Guardian Date Signature of School Official Date

Office of Language and Cultural Education Revised: Dec 2007 Notes:

• The school staff who enrolls the student is required to obtain answers from the parent/legal guardian

• If the parent/guardian does nor speak English and the school does not have staff who speaks the parent/guardian’s language, identify the language spoken by the parent/guardian through any assistance available in the school (including students).

• If exact name of the language cannot be determined, enter the code for “Other” (099) as a temporary entry. The exact language must be determined within two weeks after the enrollment. Assistance from Area Compliance Facilitators is available.

• If multiple languages are specified in response to either of the two questions, ask the parent/guardian for the language of his/her choice.

***For Language Code Lists, see back.

Home Language Code

Enter the appropriate language code (from the back of this form) on this

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HOME LANGUAGE CODE LIST

LIST OF LANGUAGE CODE (Language Sequence)

CODE LANGUAGE CODE LANGUAGE CODE LANGUAGE CODE LANGUAGE

001 SPANISH 035 RUSSIAN 072 MENOMINEE 119 KONKANI

002 GREEK 036 CEBUANO (VISAYAN) 073 CAMBODIAN (KHMER) 120 KRIO

003 ITALIAN 037 GUJARATI 074 LAO 121 KURDISH

004 POLISH 038 LATVIAN 075 SHONA 122 LINGALA

005 GERMAN 039 SIOUX (DAKOTA) 076 AFRIKAAN (TAAL) 123 LUGANDA 006 ALGONQUIN 040 NORWEGIAN 077 NEPALI 124 LUYIA (LUHYA)

007 SERBIAN 041 DANISH 078 MARATHI 125 LUNDA

008 KOREAN 042 ALBANIAN, CHEG 079 ONEIDA 126 YOMBE

009 PILIPINO (TAGALOG) (KOSOSVO/MACEDONIA) 080 HAUSAN 127 OKINAWAN

010 ARABIC 043 COMANCHE 082 PIMA 128 ORIYA

011 JAPANESE 044 FINNISH 084 PUEBLO 129 ORRI (ORING)

012 FRENCH 045 SLOVAK 085 IBO 131 PASHTO (PUSHTO)

013 SAMOAN 046 SWAHILI 086 TELUGU (TELEGU) 132 SIKKIMESE 014 HINDI 047 TAIWANESE (FORMOSAN) 087 CHOCTAW 133 SINDHI

015 BURMESE 048 CREEK 088 WINNEBAGO 134 SINHALESE

016 YIDDISH 049 HAITIAN - CREOLE 090 YORUBA 135 SOTHO

017 LITHUANIAN (049 AND 118 COMBINED) 091 MALTESE 137 TIBETAN 018 UKRANIAN 050 CHIPPEWA 093 ROMANY (GYPSY) 139 KACHE (KAJE, JJU)

019 HUNGARIAN 052 EWE 094 TAMIL 142 KPELLE

020 CZECH 053 PANJABI (PUNJABI) 095 HOPI 143 ILONGO (HILIGAYNON) 021 CANTONESE (CHINESE) 055 BULGARIAN 096 SLOVENIAN 144 EFIK

022 THAI 056 APACHE 097 CHEROKEE 146 MIEN (YAO)

023 PORTUGUESE 057 GAELIC (SCOTTISH) 098 CROW 147 CHADCHOW/TEDCHIU

024 SWEDISH 058 MACEDONIAN 102 GAELIC (IRISH) (CHINESE)

025 ASSYRIAN 059 MALAY 103 AKAN (FANTE, ASANTE) 148 FUKIEM/HOKKIEN (SYRIAC, ARAMAIC) 060 MALAYALAM 104 TULUAU (CHINESE) (Old 113) 026 ARMENIAN 061 NAVAJO 105 AMHARIC 149 HAINANESE (CHINESE) 027 ROMANIAN 062 INDONESIAN 107 BALINESE 150 SHANGAHI (CHINESE) 028 DUTCH/FLEMISH 063 KANNADA (KANARESE) 108 CHAMORRO 151 CROATIAN

029 HEBREW 064 ESTONIAN 111 ESKIMO 152 BOSNIAN

030 MANDARIN 065 FLEMISH 113 HAKKA (CHINESE) 153 ALBANIAN, TOSK

031 FARSI (PERSIAN) 066 KASHMIRI 114 WELSH 162 MAAY

032 TURKISH 067 BENGALI 115 GUYANESE 163 KRAHN

033 URDU 068 HIMONG 116 USE 049 (Haitian) 199 MONGOLIAN

034 VIETNAMESE 070 ICELANDIC 118 PAMPANGAN 099 OTHER

LIST OF LANGUAGE CODE (Language Sequence) IN ALPHABETICAL ORDER

076 AFRIKAAN (TAAL) 064 ESTONIAN 142 KPELLE 023 PORTUGUESE

103 AKAN (FANTE, ASANTE) 052 EWE 163 KRAHN 084 PUEBLO

042 ALBANIAN, CHEG 031 FARSI (PERSIAN) 120 KRIO 027 ROMANIAN (KOSOSVO/MACEDONIA) 044 FINNISH 121 KURDISH 093 ROMANY (GYPSY)

153 ALBANIAN, TOSK 065 FLEMISH 074 LAO 035 RUSSIAN

006 ALGONQUIN 012 FRENCH 038 LATVIAN 013 SAMOAN

105 AMHARIC 148 FUKIEM/HOKKIEN 122 LINGALA 007 SERBIAN

056 APACHE (CHINESE) (Old 113) 017 LITHUANIAN 150 SHANGAHI (CHINESE)

010 ARABIC 102 GAELIC (IRISH) 123 LUGANDA 075 SHONA

026 ARMENIAN 057 GAELIC (SCOTTISH) 125 LUNDA 132 SIKKIMESE

025 ASSYRIAN 005 GERMAN 124 LUYIA (LUHYA) 133 SINDHI

(SYRIAC, ARAMAIC) 002 GREEK 162 MAAY 134 SINHALESE

107 BALINESE 037 GUJARATI 058 MACEDONIAN 039 SIOUX (DAKOTA)

067 BENGALI 115 GUYANESE 059 MALAY 045 SLOVAK

152 BOSNIAN 149 HAINANESE (CHINESE) 060 MALAYALAM 096 SLOVENIAN 055 BULGARIAN 049 HAITIAN - CREOLE 091 MALTESE 135 SOTHO 015 BURMESE (049 AND 118 COMBINED) 030 MANDARIN 001 SPANISH 073 CAMBODIAN (KHMER) 113 HAKKA (CHINESE) 078 MARATHI 046 SWAHILI 021 CANTONESE (CHINESE) 080 HAUSAN 072 MENOMINEE 024 SWEDISH

036 CEBUANO (VISAYAN) 029 HEBREW 146 MIEN (YAO) 047 TAIWANESE/FORMOSAN

108 CHAMORRO 014 HINDI 199 MONGOLIAN 094 TAMIL

147 CHADCHOW/TEDCHIU 068 HIMONG 061 NAVAJO 086 TELUGU (TELEGU)

(CHINESE) 095 HOPI 077 NEPALI 022 THAI

097 CHEROKEE 019 HUNGARIAN 040 NORWEGIAN 137 TIBETAN

050 CHIPPEWA 085 IBO 116 USE 049 (Haitian) 104 TULUAU

087 CHOCTAW 070 ICELANDIC 127 OKINAWAN 032 TURKISH

043 COMANCHE 143 ILONGO (HILIGAYNON) 079 ONEIDA 018 UKRANIAN

048 CREEK 062 INDONESIAN 128 ORIYA 033 URDU

151 CROATIAN 003 ITALIAN 129 ORRI (ORING) 034 VIETNAMESE

098 CROW 011 JAPANESE 118 PAMPANGAN 114 WELSH

020 CZECH 139 KACHE (KAJE, JJU) 053 PANJABI (PUNJABI) 088 WINNEBAGO 041 DANISH 063 KANNADA (KANARESE) 131 PASHTO (PUSHTO) 016 YIDDISH 028 DUTCH/FLEMISH 066 KASHMIRI 009 PILIPINO (TAGALOG) 126 YOMBE

144 EFIK 119 KONKANI 082 PIMA 090 YORUBA

111 ESKIMO 008 KOREAN 004 POLISH 099 OTHER

Chicago Public Schools

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S

TATE OF

I

LLINOIS

D

EPARTMENT OF HUMAN SERVICES

C

ERTIFICATE OF

C

HILD

H

EALTH

E

XAMINATION

Please Print

Student’s Name

Last First Middle

Birth Date

Month/Day/ Year

Sex

School

Grade Level /ID#

Address Street City ZIP code

Parent/ Telephone #

Guardian Home Work

IMMUNIZATIONS:

To be completed by health care provider. Note the mo/da/yr for every dose administered. The day and month is required if you cannot determine if the vaccine was given after the minimum interval or age. If a specific vaccine is medically contraindicated, a separate written statement must be attached explaining

the medical reason for the contraindication. VACCINE/DOSE 1 MO DA YR 2 MO DA YR 3 MO DA YR 4 MO DA YR 5 MO DA YR 6 MO DA YR

Diphtheria, Tetanus and Pertussis (DTP or DTaP)

Diphtheria and Tetanus (Pediatric DT or Td) Inactivated Polio (IPV)

Oral Polio (OPV)

Haemophilus influenzae type b (Hib) Hepatitis B (HB)

Varicella (Chickenpox)

Combined Measles, Mumps and Rubella

(MMR)

Measles (Rubeola) Rubella (3-day measles) Mumps

Comments

¨PCV7 ¨PPV23 ¨PCV7 ¨PPV23 ¨PCV7 ¨PPV23 ¨PCV7 ¨PPV23 ¨PCV7 ¨PPV23 ¨PCV7 ¨PPV23 Pneumococcal (not required for school entry)

Check specific type (PCV7, PPV23)

Other (Specify hepatitis A, meningococcal, etc.)

Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above immunization history must sign below.

Signature Title Date

Signature

(If adding dates to the above immunization history section, put your initials by date(s) and sign here.) Title Date

Signature

(If adding dates to the above immunization history section, put your initials by date(s) and sign here.)

Title Date

ALTERNATIVE PROOF OF IMMUNITY

1. Clinical diagnosis is acceptable if verified by physician.

*(All measles cases diagnosed on or after July 1, 2002, must be confirmed bylaboratory evidence.)

*MEASLES (Rubeola) MO DA YR MUMPS MO DA YR VARICELLA MO DA YR Physician’s Signature 2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official.

Person signing below is verifying that the parent/guardian’s description of varicella disease history is indicative of past infection and is accepting such history as documentation of disease. Date of Disease Signature Title Date

3. Laboratory confirmation (check one) ¨

¨ Measles ¨

¨ Mumps ¨

¨ Rubella ¨

¨ Hepatitis B ¨

¨ Varicella

Lab Results Date MO DA YR (Attach copy of lab report, if available.)

VISION AND HEARING SCREENING DATA

Pre-school – annually beginning at age 3; School age – during school year at required grade levels

Date Age/Grade R L R L R L R L R L R L R L R L R L R L Vision

Hearing Code: P = Pass F = Fail U = Unable to test R = Referred G/C = Glasses/ Contacts Printed by Authority of the State of Illinois

(Complete Both Sides)

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Student’s Name

Birth Date

Sex School Grade Level/ ID #

Last First Middle

Month/Day/ Year

HEALTH HISTORY TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER ALLERGIES (Food, drug, insect, other) MEDICATION (List all prescribed or taken on a regular basis.)

Diagnosis of asthma?

Child wakes during the night coughing

Yes No Yes No

Indicate Severity Loss of function of one of paired

organs? (eye/ear/kidney/testicle) Yes No

Birth defects? Yes No Developmental delay? Yes No

Hospitalizations?

When? What for? Yes No

Blood disorders? Hemophilia,

Sickle Cell, Other? Explain. Yes No

Surgery? (List all.)

When? What for? Yes No Diabetes? Yes No Serious injury or illness? Yes No Head injury/Concussion/Passed out? Yes No TB skin test positive (past/present)? Yes* No Seizures? What are they like? Yes No TB disease (past or present)? Yes* No

*If yes, refer to local health department.

Heart problem/Shortness of breath? Yes No Tobacco use (type, frequency)? Yes No Heart murmur/High blood pressure? Yes No Alcohol/Drug use? Yes No Dizziness or chest pain with

exercise? Yes No

Family history of sudden death

before age 50? (Cause?) Yes No

Dental ¨Braces ¨Bridge ¨Plate Other

Eye/Vision problems? _____ Glasses ¨ Contacts ¨ Last exam by eye doctor _______

Other concerns? (crossed eye, drooping lids, squinting, difficulty reading) _{Other concerns?}

Ear/Hearing problems? _{Yes No}

Bone/Joint problem/injury/scoliosis? Yes No

Information may be shared with appropriate personnel for health and educational purposes.

Parent/Guardian

Signature Date

Entire section below to be completed by MD/DO/APN/PA

(

*INDICATES TESTING MANDATED FOR STATE LICENSED CHILD CARE FACILITIES) Yes No

PHYSICAL EXAMINATION REQUIREMENTS HEIGHT WEIGHT BMI B/P

DIABETES SCREENING BMI>>85% age/sex Yes ¨ No ¨ And any two of the following: Family History Yes ¨ No ¨ Ethnic Minority Yes ¨ No ¨

Signs of Insulin Resistance (hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans) Yes ¨ No ¨ At Risk Yes ¨ No ¨

LEAD RISK QUESTIONNAIRE* Required for children age 6 months through 6 years enrolled in licensed or public school operated day care, preschool, nursery school and/or kindergarten.

Blood Test Indicated? Yes¨¨ No¨¨ Blood Test Date Blood Test Result (Blood test required in Chicago and other high risk zip codes.)

TB SKIN TEST Recommended only for children in high-risk groups including children who are immunosuppressed due to HIV infection or other conditions, recent immigrants from high prevalence countries, or those exposed to adults in high-risk categories. See CDC guidelines. Date Read / / Result mm

LAB TESTS *INDICATES TESTING MANDATED FOR STATE LICENSED CHILD CARE FACILITIES

Date Results Date Results

Hemoglobin * or Hematocrit * Sickle Cell * (as indicated)

Urinalysis Other

SYSTEM REVIEW Normal Comments/Follow-up/Needs Normal Comments/Follow-up/Needs

Skin Endocrine

Ears Gastrointestinal

Genito-Urinary LMP

Eyes Normal Yes¨ No¨ Objective screening Yes¨ No¨ Result______________

Amblyopia Yes¨ No¨ Referred to Opthalmologist/Optometrist Yes¨ No¨ _Neurological

Nose Musculoskeletal

Throat Spinal examination

Mouth/Dental Nutritional status

Cardiovascular/HTN

Respiratory Mental Health

NEEDS/MODIFICATIONS required in the school setting DIETARY Needs/Restrictions

SPECIAL INSTRUCTIONS/DEVICES e.g. safety glasses, glass eye, chest protector for arrhythmia, pacemaker, prosthetic device, dental bridge, false teeth, athletic support/cup

MENTAL HEALTH/OTHER Is there anything else the school should know about this student?

If you would like to discuss this student’s health with school or school health personnel, check title: ¨ Nurse ¨ Teacher ¨ Counselor ¨ Principal

EMERGENCY ACTION needed while at school due to child’s health condition (e.g., seizures, asthma, insect sting, food, peanut allergy, bleeding problem, diabetes, heart problem)?

Yes¨ No ¨ If yes, please describe.

On the basis of the examination on this day, I approve this child’s participation in (If No or Modified,please attach explanation.)

PHYSICAL EDUCATION Yes ¨¨ No ¨¨ Modified ¨¨ INTERSCHOLASTIC SPORTS (for one year) Yes ¨¨ No ¨¨ Limited ¨¨

Physician/Advanced Practice Nurse/Physician Assistant performing examination

Print Name Signature Date

Address Phone

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