2012-13 VAVA EFP

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

submit documentation 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:

1-877-843-5902 [email protected] Virginia Virtual Academy

2300 Corporate Park DriveSuite 200Herndon, VA 20171

Virginia Virtual Academy - A program o

the Carroll County School District

Enrollment Processing Center

2300 Corporate Park Drive

Suite 200

Herndon, VA 20171

Ph. 1.877.382.6514

Fx. 1.877.843.5902

www.k12.com/vava

Required For? Item Description Provided by?

Required or all

Students

Proo o Age Ocial Birth Certifcate (not the hospital issued certifcate) Provided by you

Proo o ResidencyDrivers License, Utility bill showing current address OR Mortgage Statement/

Rental contract including signature page.Provided by you

Hearing, Vision and

Immunization

Part 1. This section is flled out by the Parent/Guardian. Part 2. This orm is

completed by your students physician. Part 3. This orm is completed by your

students physician.

Provided in this

packet

Notifcation o O-

ense FormPlease complete and submit.

Provided in this

packet

Family Income

FormPlease complete and submit.

Provided in this

packet

Home Language

Survey

Please complete and submit.Provided in this

packetSchool Ethnicity

SurveyPlease complete and submit.

Provided in

packet

Release o Records

By flling out this orm, you are giving our school permission to request your

students ocial records rom their previous school ater the approval process.

I your child is enrolling in Kindergarten or was Homeschooled please indicate it

on the orm, fll out the top portion and sign it.

Provided in this

packet

Required or all

students residing

outside o the Car-

roll County School

District

Application or

Admission as a

Non-Resident

Please complete and submit.Provided in this

packet

Required or

student with anIEP or other Special

Education needs

IEP

A copy o your students current IEP (Individualized Education Plan). Because

the IEP expires yearly, please submit the current IEP. Provided by you

Evaluation ReportThe Evaluation Report is valid or 3 years. I you do not have a copy o your

students ER, you can request a copy rom your students current school.Provided by you

Required or stu-

dents that have a

504 plan

504 Accommoda-

tion Plan

A copy o your students current 504 Accommodation Plan. Because the 504

expires yearly, please submit the current 504.Provided by you
mailto:vavafax%40k12.com?subject=Student%20Name%3Ahttp://www.k12.com/vava/http://www.k12.com/vava/mailto:vavafax%40k12.com?subject=Student%20Name%3A

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MCH 213 G r evised 10/2010 1

COMMONWEALTH OF VIRGINIASCHOOL ENTRANCE HEALTH FORM

Health Information Form/Comprehensive Physical Examination Report/Certification of Immunization

Part IHEALTH INFORMATION FORM

State law (Ref. Code of Virginia 22.1-270) requires that your child is immunized and receives a comprehensive physical examination before entering public

kindergarten or elementary school. The parent or guardian completes this page (Part I) of the form. The Medical Provider completes Part II and Part III of the

form. This form must be completed no longer than one year before your childs entry into school.

Name of School: ____________________________________________________________________________________ Current Grade: _______________________

Students Name: _________________________________________________________________________________________________________________________

Last First Middle

Students Date of Birth: _____/_____/_______ Sex: _______ State or Country of Birth: ________________________ Main Language Spoken: ______________

Students Address: ______________________________________________________ City: ____________________ State: _______________ Zip: _______________

Name of Mother or Legal Guardian: ______________________________________________ Phone: ______ -______-________ Work or Cell: _____-_____-______

Name of Father or Legal Guardian: ______________________________________________ Phone: ______ -______-________ Work or Cell: _____-_____-______

Emergency Contact: __________________________________________________________ Phone: ______ -______-________ Work or Cell: _____-_____-______

Condition Yes Comments Condition Yes Comments

Allergies (food, insects, drugs, latex) DiabetesAllergies (seasonal) Head injury, concussions

Asthma or breathing problems Hearing problems or deafness

Attention-Deficit/Hyperactivity Disorder Heart problems

Behavioral problems Lead poisoning

Developmental problems Muscle problems

Bladder problem Seizures

Bleeding problem Sickle Cell Disease (not trait

Bowel problem Speech problems

Cerebral Palsy Spinal injury

Cystic fibrosis Surgery

Dental problems Vision problems

Describe any other important health-related information about your child (for example, feeding tube, hospitalizations , oxygen support, hearing aid, etc.):

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

List all prescription, over-the-counter, and herbal medications your child takes regularly:

_______________________________________________________________________________________________________________________________________

Check here if you want to discuss confidential information with the school nurse or other school authority. Yes No

Please provide the following information:

Name Phone Date of Last Appointment

Pediatrician/primary care provider

Specialist

Dentist

Case Worker (if applicable)

Childs Health Insurance: ____ None ____ FAMIS Plus (Medicaid) _____ FAMIS _____ Private/Commercial/Employer sponsored

I, ______________________________________ (do___) (do not___) authorize my childs health care provider and designated provider of health care in theschool setting to discuss my childs health concerns and/or exchange information pertaining to this form. This authorization will be in place until or unless you

withdraw it. You may withdraw your authorization at any t ime by contacting your childs school. When information is released from your childs record,documentation of the disclosure is maintained in your childs health or scholastic record.

Signature of Parent or Legal Guardian: ______________________________________________________________________Date: _______/________/ __________

Signature of person completing this form: ____________________________________________________________________Date:_______/________/___________

Signature of Interpreter: ____________________________________________________________________ ______________Date: ______/_____/_______

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MCH 213 G r evised 10/2010 2

COMMONWEALTH OF VIRGINIA

SCHOOL ENTRANCE HEALTH FORM

Part II - Certification of Immunization

Section I

To be completed by a physician or his designee, registered nurse, or health department official.

See Section II for conditional enrollment and exemptions.

A copy of the immunization record signed or stamped by a physician or designee, registered nurse, or health department

official indicating the dates of administration including month, day, and year of the required vaccines shall be acceptable

in lieu of recording these dates on this form as long as the record is attached to this form.

Only vaccines marked with an asterisk are currently required for school entry. Form must be signed and dated by the

Medical Provider or Health Department Official in the appropriate box.

Certification of Immunization 11/06

Students Name: Date of Birth: |____|____|____|

Last First Middle Mo.Day Yr.

IMMUNIZATION RECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN

*Diphtheria, Tetanus, Pertussis (DTP, DTaP) 1 2 3 4 5

*Diphtheria, Tetanus (DT) or Td (given after 7

years of age) 1 2 3 4 5

*Tdap booster (6th grade entry) 1

*Poliomyelitis (IPV, OPV) 1 2 3 4

*Haemophilus influenzae Type b

(Hib conjugate)

*only for children

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MCH 213 G r evised 10/2010 3

Students Name: Date of Birth: |____ |_ ___|___ _|

Section IIConditional Enrollment and Exemptions

Complete the medical exemption or conditional enrollment section as appropriate to include signature and date.

Certification of Immunization 10/2010

MEDICAL EXEMPTION: As specified in the Code of Virginia 22.1-271.2, C (ii), I certify that administration of the vaccine(s) designated below would bedetrimental to this students health. The vaccine(s) is (are) specifically contraindicated because (please specify):

________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________.

DTP/DTaP/Tdap:[ ]; DT/Td:[ ]; OPV/IPV:[ ]; Hib:[ ]; Pneum:[ ]; Measles:[ ]; Rubella:[ ]; Mumps:[ ]; HBV:[ ]; Varicella:[ ]

This contraindication is permanent: [ ], or temporary [ ] and expected to preclude immunizations until: Date (Mo., Day, Yr.): |___|___|___|.

Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.):|___|___|___|

RELIGIOUS EXEMPTION: The Code of Virginia allows a child an exemption from receiving immunizations required for school attendance if the student or the

students parent/guardian submits an affidavit to the schools admitting official stating that the administration of immunizi ng agents conflicts with the students religio

tenets or practices. Any student entering school must submit this affidavit on a CERTIFICATE OF RELIGIOUS EXEMPTION (Form CRE-1), which may be obtaineany local health department, school division superintendents office or local department of social services. Ref. Code of Virginia 22.1-271.2, C (i).

CONDITIONAL ENROLLMENT: As specified in the Code of Virginia 22.1-271.2, B, I certify that this child has received at least one dose of each of the vaccine

required by the State Board of Health for attending school and that this child has a plan for the completion of his/her requirements within the next 90 calendar days. N

immunization due on __________________.

Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.):|___|___|___|

For Minimum Immunization Requirements for Entry into School and

Day Care, consult the Division of Immunization web site at

http://www.vdh.virginia.gov/epidemiology/immunization

Children shall be immunized in accordance with the Immunization Schedule developed and published bthe Centers for Disease Control (CDC), Advisory Committee on Immunization Practices (ACIP), the

American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP),

otherwise known as ACIP recommendations (Ref. Code of Virginia 32.1-46(a)).

(requirements are subject to change.)

Section III

Requirements
http://www.vdh.virginia.gov/epidemiology/immunizationhttp://www.vdh.virginia.gov/epidemiology/immunization

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MCH 213 G r evised 10/2010 4

Part III -- COMPREHENSIVE PHYSICAL EXAMINATION REPORT

A qualified licensed physician, nurse practitioner, or physician assistant must complete Part III . The exam must be done no longer than one year before entry

into kindergarten or elementary school (Ref. Code of Virginia 22.1-270). Instructions for completing this form can be found at www.vahealth.org/schoolhealth

Students Name: _______________________________________________ Date of Birth: _____/_____/__________ Sex: M F

HealthAssessment

Date of Assessment: _____/_____/_______

Weight: ________lbs. Height: _______ ft. ______ in.

Body Mass Index (BMI): ___________ BP____________

Age / gender appropriate history completed

Anticipatory guidance provided

TB Risk Assessment: No Risk Positive/ReferredMantoux results: __________________mm

Physical Examination

1 = Within normal 2 = Abnormal finding 3 = Referred for evaluation or treatment

1 2 3 1 2 3 1 2 3

HEENT Neurological Skin

Lungs Abdomen Genital

Heart Extremities Urinary

EPSDT Screens Required for Head Startinclude specific results and date:Blood Lead:___________________________________________ Hct/Hgb ____________________________________________

Developmental

Screen

Assessed for: Assessment Method: Within normal Concern identified: Referred for Evaluation

Emotional/Social

Problem Solving

Language/Communication

Fine Motor Skills

Gross Motor Skills

Hearing

Screen

Screened at 20dB: Indicate Pass (P) or Refer (R) in each box.

1000 2000 4000

R

L

Screened by OAE (Otoacoustic Emissions): Pass Refer

Referred to Audiologist/ENT Unable to testneeds rescreen

Permanent Hearing Loss Previously identified: ___Left ___Right

Hearing aid or other assistive device

Vision

Screen

With Corrective Lenses (check if yes)

Stereopsis Pass Fail Not tested

Distance Both R L Test used:

20/ 20/ 20/

Pass Referred to eye doctor Unable to testneeds rescreen

Dental

Screen

Problem Identified: Referred for treatment

No Problem: Referred for prevention

No Referral: Already receiving dental care

Recommen

dat

ions

to(Pre

)Sc

hoo

l,

ChildCare,

or

Ear

ly

Interven

tion

Personne

l

Summary of Findings (check one):

Well child; no conditions identified of concern to school program activities

Conditions identified that are important to schooling or physical activity (complete sections below and/or explain here): ____________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________

___ Allergy food: _____________________ insect: _____________________ medicine: _____________________ other: _________________Type of allergic reaction: anaphylaxis local reaction Response required: none epi pen other: _______________________________

___Individualized Health Care Plan needed (e.g., asthma, diabetes, seizure disorder, severe allergy, etc)

___ Restricted Activity Specify: _________________________________________________________________________________________________

___ Developmental Evaluation Has IEP Further evaluation needed for: ___________________________________________________________

___ Medication. Child takes medicine for specific health condition(s). Medication must be given and/or available at school.

___ Special Diet Specify: ______________________________________________________________________________________________________

___ Special Needs Specify: ______________________________________________________________________________________________________

Other Comments: _____________________________________________________________________________________________________________

Health Care Professionals Certification (Write legibly or stamp):

Name : _____________________________________ Signature:________________________________________ Date: ____/_____/______

Practice/Clinic Name: __________________________________________ Address: ____________________________________________________________

Phone: _______-_______-____________________ Fax: _______-_______-_____________________ Email: _________________________________________

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Virginia Virtual Academy - A program o




Suite 200

Herndon, VA 20171

Ph. 1.866.654.8297

Fx. 1.877.843.5902

www.k12.com/vava

Notification of Offense Form

Parental Registration Statement:

Student Name:

Date o Birth: Grade:

Please choose one o the ollowing options and sign:

1. I, __________________________, arm that my student, _________________________, was NOT previously suspended or ex-

pelled rom any public or private school o this Commonwealth or any other State or an act or oense involving weapons, alcoho

or drugs, or or the willul infiction o injury to another person or any act o violence committed on school property.

OR

2. I, __________________________, arm that my student, _________________________, WAS previously suspended or expelled

rom any public or private school o this Commonwealth or any other State or an act or oense involving weapons, alcohol or

drugs, or or the willul infiction o injury to another person or any act o violence committed on school property. My student was

suspended or expelled rom the ollowing school(s):

My student was (check one o the ollowing)o suspended or o expelled rom the ollowing school(s):

School Name: ______________________________________________________________

Address: __________________________________________________________________

Telephone Number: _________________________________________________________

Expulsion/Suspension Start Date_________________

Expulsion/Suspension End Date__________________

My student was suspended or expelled or the ollowing reason(s):

(Please check all that apply)

o oense involving weapons

o oense involving alcohol

o oense involving drugs

owillul infiction o injury to another person

o

an act o violence committed on school propertyo other (please note below)

Additional comments: _________________________________________________________

Signature ______________________________________________Date _______________

Students Name: Students Home Phone:1
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Carroll County Public Schools

Student Home Language Survey

Students Name: __________________________________________ Date: _____________________________

Grade: _____________ Teacher: __________________________ School: _____________________________

Relationship of Person Completing Survey:

Mother Father Guardian Other (specify): _______________________________

Check the best answer to each question:

1. Was the first language learned by the student English? Yes No

2. Can the student speak languages other than English? Yes No

Which other languages? __________________________________________

3. Which language does the student use most often when speaking to friends?

English Other language: ___________________________

4. Which language does the student use most often when speaking to his/her parents?

English Other language: ___________________________

5. Does anyone in your home speak a language other than English? Yes No

Which other language? ___________________________________________

6. Have you moved in order to obtain agriculture work in the past 36 months? Yes No

7. In what country was the student born? ___________________________________

8. Is the student: US Citizen Immigrant Refugee

_________________________________________________ _____________________________________

Parent Name Print Date

_________________________________________________ _____________________________________

Parent or Guardian Signature Date

Office use only:

o If the answer to Number 2 is yes, and other languages are given as answers to numbers 3, 4, or 5,the students English abilities should be tested even if the students oral ability is good. In this case, a

copy of this form should be given to the schools ESL teacher and the divisions ESL coordinator.

o One copy of this form should be kept in the students permanent record.

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Carroll County Public Schools Ethnicity Survey

Please Print

Students Last Name

Students First Name

Students Middle Name

Students Current Grade

Students Current School

Part A and Part B must be completed

Part A. Is this student Hispanic/Latino?(Choose only one)

No, Not Hispanic/Latino

Yes, Hispanic/Latino (A person of 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 marking one or more boxes to indicate what you

consider your students race to be.

Part B. What is the students race? (Choose one or more)

American Indian or Alaska Native(A person having origins in any of the original peoples ofNorth and South America (including Central America), and who maintains tribal affiliation or

community attachment.)

Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, orIndian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia,

Pakistan, the Philippne 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 originalpeoples of Hawaii, Guam, Samoa, or other Pacific Isalnds.)

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

North Africa.)

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Virginia Virtual Academy - A program of




Suite 200

Herndon, VA 20171

Ph. 1.866.654.8297

Fx. 1.877.843.5902

www.k12.com/vava

Student Information

Students Full Name:first middle last

Students Date of Birth: Students Social Security Number:

Students 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:

Schools Address:street

city county state zip

Schools Phone: Schools Fax:

Name of Parent or Legal Guardian:first last

Parent/Guardians 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: Virginia Virtual Academy


2300 Corporate Park Drive, Suite 200

Herndon, VA 20171

Students Name: Students Home Phone:7
http://www.k12.com/vava/http://www.k12.com/vava/

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CARROLL COUNTY PUBLIC SCHOOLS

605-9 PINE STREET

HILLSVILLE, VIRGINIA 24343

(276) 728-3191

(276) 236-8145

APPLICATION FOR ADMISSION AS A NON-RESIDENT STUDENT

For School Year ________________

Students Name _________________________________________________________________

LAST FIRST MIDDLE

Date of Birth _______________________________ Age ______ Male ____ Female ____

MONTH DAY YEAR

Name of Parent(s) or Legal Guardian(s) __________________________________________________

Current Legal Address (911) ___________________________________________________________

Mailing Address ____________________________________________________________________

Home Telephone ____________________ Work Telephone _____________ Cell ________________

County or City of Residence ___________________

Name, Address, and Telephone Number of School Last Attended By Student:

_____________________________________________________________

_________________________________________________________________________________________________________________________

Reason for Leaving Previous School:__________________________________________________________________________________

If the Student Has Been Enrolled in Any Special Education Programs in the School(s) Last Attended,

Please Specify: ______________________________________________________________________

School Requesting to Attend: __________________________________ Grade: _________________

Why Do You Wish to Enroll Your Child in Carroll County Public Schools?

__________________________________________________________________________________

I certify that the information in this application is true and accurate to the best of my knowledge

and that I have been provided, read, understood, and signed the Student School Assignment

Guidelines.

____________________ _______________________________________

Date Signature of Parent/Guardian

I affirm that the above name student has not been suspended or expelled from school attendance

at a private or public school nor has been assigned to any correctional facility or placed on

probation by the court system.

____________________ _______________________________________

Date Signature of Parent/Guardian (OVER)

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CARROLL COUNTY PUBLIC SCHOOLS

STUDENT SCHOOL ASSIGNMENTS

NON-RESIDENT STUDENT REQUESTS

Consideration of a request to register a non-resident student from another school division in Virginia is contingent

upon the following:

1. Completion of an APPLICATION FOR ADMISSION AS A NON-RESIDENT STUDENT. Applications must be

returned to the Office of the Division Superintendent.

2. Availability of space in the grade level and/or program which is indicated by current placement. Acceptance and/or

continued enrollment of a non-resident student will not require the initiation of a new program, the employment of additional

personnel, the alteration of existing facilities, or the payment of special services beyond those provided in the Carroll County

Public Schools. The approval of a non-resident student application will be subject to maintaining available space in a grade

level/program for students who may move into the attendance area.

3. Continued enrollment of a non-resident student is subject to annual review. All non-resident student applications

will be subject to renewal on an annual basis. Continuation applications must be received in the Office of the Superintendent

within the designated timeline otherwise the application will be processed as a new request. Continued placement in a Carroll

County School by a non-resident student will be contingent upon available space, programs, discipline, and school attendance.

Students are subject to all policies, regulations, and guidelines of the school division and the Carroll County Public Schools

Student Handbook. Notification of approval will be on an annual basis.

4. The superintendent will approve or deny non-resident student applications based upon a review of the application,

recommendation by school principal or others as necessary, and the availability of space and/or programs.

5. Approval of non-resident student status may be revoked. Non-resident students would be expected to return to the

school division in which they reside when their enrollment creates any of the conditions described above in numbers two and

three. Transfer to another school in Carroll County is subject to the same approval process.

6. Transportation of non-resident students is the responsibility of the parent or guardian. Non-resident transfer

students may board a bus at a bus stop that serves the school they have been approved to attend.

7. Any transfer request that is received and/or approved based upon false or misleading information will be

declared void and the transfer will be rescinded.

8. The superintendent reserves the right to remove the privilege to attend Carroll County Public Schools.

9. Failure to meet any of the above criteria will result in an immediate removal from Carroll County Public Schools.

_____________________ ___________________________________

DATE Signature Parent or Guardian

OUT OF STATE STUDENT REQUESTS

Consideration of a request to register a non-resident student from another state is contingent upon the following:

1. All criteria set forth in aforementioned non-resident guidelines of student school assignments.2.

Payment of any applicable tuition charges prior to enrollment.

3. If, for any reason, the parent does not remit tuition within the prescribed time limit, the approval for transfermay be rescinded. If payment is not made, determination for future enrollment as a transfer student will be

denied.

_____________________ ___________________________________

DATE Signature Parent or Guardian

ADOPTED: 08/04/93

03/29/05

10/10/06

Documents

2012-13 VAVA EFP