Texas Virtual Academy Enrollment Processing Center 2300 Corporate Park Drive, Ste 200 Herndon, VA 20171 Ph. 877.554.1084 Fx. 877.257.4612 www.k12.com/txva

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): 1-877-257-4612

Scan and Email: [email protected]



2300 Corporate Park Drive, Ste 200



Required For?

Mail: Texas Virtual Academy Herndon, VA 20171

Item

Description

Provided by?

Proof of Prior Texas Public

You must submit a proof of prior public in a Texas public school. Items (Report Card, Transcript, and/ Verification of Enrollment Form filled out by your previous Texas public school for the 2012-2013 School year. * Verification of Enrollment Form provided in this packet. This form must be filled out by your students previous school personnel.

Provided by you

Proof of Age

Official Birth Certificate (not the hospital issued certificate)

Provided by you

Legal Guardian Drivers License or State ID

Please submit a copy of the Legal Guardian’s Drivers License or State ID.

Provided by you

Proof of Residency

Two forms of Proof of Residency: Current Utility bill showing service address, Mortgage statement/Rental contract including signature page, recent tax statement.

Provided by you

Proof of Internet

Proof of Internet service.

Provided by you

RES Student Enrollment Application

Complete this form and submit.

Provided in this packet

Immunization Record

Current Immunization Record

Provided by you

Home Language Survey

Complete this form and submit.

Provided in this packet

Occupational Survey

Complete this form and submit.

Provided in this packet

Ethnicity and Race Questionnaire

Please write your student’s name, as it was entered on the application.

Provided in this packet

Student Record Release

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

State Compensatory Form

Complete this form and submit (Example page included for instructions on how to complete this form)

Provided in this packet

Affidavit of Student Residency

Complete this form and submit.

Provided in this packet

ESL Parent Permission Letter

Complete this form and submit

Provided in this packet

Special Education

Complete this form and submit.

Provided in this packet

504 Plan

Complete this form and submit.

Provided in this packet

Student Health History

Complete this form and submit.

Provided in this packet

At Risk Indicators

Complete this form and submit.

Provided in this packet

Recommended for 3rd, 5th and 7th Graders

Vision and Screening Hearing

Please submit proof that your student has completed their vision and hearing screening from previous school.

Provided by you

Recommended for 6th and 9th Graders

Spinal Screenin

Please submit proof that your student has completed their spinal screening from previous school.

Provided by you

Report Card

The most recent Report Card

Provided by you

Social Security Card

Please note do not send actual card, please submit a copy

Provided by You

Transcripts

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 through 11th graders. Once your student is approved, we will receive the official transcript directly from the school.

Provided by you

IEP

A copy of your student’s current IEP (Individualized Education Plan). Because the IEP expires yearly, please submit the current IEP. * Highly recommended to submit with enrollment documents.

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. * Highly recommended to submit with enrollment documents.

Provided by you

504 Accommodation Plan

A copy of your student’s current 504 Accommodation Plan. Because the 504 expires yearly, please submit the current 504. * Highly recommended to submit with enrollment documents.

Provided by you

Required for all Students

Recommended for All Students Recommended for all rising 10 -11th Grade Students

Recommended for student with an IEP or other Special Education needs

Recommended for students that have a 504 plan

STUDENT ENROLLMENT APPLICATION (PLEASE PRINT) Student’s Name _____________________________________________ Application Date ____ / ____ / ______ Last

First

MI

Address _________________________________________________________________________________ City _______________________________________ State _____________________ ZIP________________ Home Phone _______________ Cell Phone ________________ Social Security # ______ - ____ - ______ Gender (circle one):

M

F

Date of birth ____ / ____ / ____ Age ______ Last grade completed _______

School District in which student resides: ____________________________

___________________

School Name *Local school the student is zoned to attend in relation to current residence and current grade level.

ISD

Last School Attended: School Name_______________________________________

Phone (______) ______ - ______________

Address _________________________________________________________________________________ City _______________________________________ State ___________________ ZIP________________ Father’s name ___________________________________________________ Living with student? __________ Employer ________________________________________________________________________________ Address _________________________________________________________________________________ City ________________________________ State ____ Zip _________ Home Phone _________________ Work phone (______) ______ - __________

Cellular phone/Pager/Etc. (______) ______ - ____________

Driver’s License # ____________________ (State)________ Email_________________________________ Mother’s name __________________________________________________ Living with student? ___________ Employer ________________________________________________________________________________ Address _________________________________________________________________________________ City ________________________________ State ____ Zip ________ Home Phone __________________ Work phone (______) ______ - __________

Cellular phone/Pager/Etc. (______) ______ - ____________

Driver’s License # ____________________ (State)_________ Email________________________________ Alternate Contact (Name) _________________________________ (Relationship)________________________ Home Phone____________________ Work Phone__________________ Cell Phone___________________ Emergency Contact (Name) __________________________________ (Relationship)______________________ Home Phone____________________ Work Phone___________________ Cell Phone__________________ How were you (was your student) referred to ResponsiveEd? __________________________________________ ________________________________________________________________________________________ Legal Alert: Is anyone legally restricted from contact with your student? (Circle one) Are copies of documents on file? (Circle one)

Yes Yes

No No

[Please continue on back] For Administrative Use Only: Official Enrollment Date _____/ _____/ _____ Official Withdrawal Date _____/ _____/ _____ (Official enrollment date is first day of attendance; official withdrawal date is indicated on withdrawal form and attendance records.)

2013-14

Affidavit of Student Residency Student (Last Name)

(First Name)

(Middle Name)

Student lives with the following person(s): _______________________________________ and/or_________________________________________ First and Last name of Father/Stepfather/Grandfather/Other

First and Last name of Mother/Stepmother/Grandmother/Other

(Circle one)

(Circle one)

At the Following Address: __________________________________________________________________ Street Address City Zip

_________________ Phone

Texas Education Code § 25.001 authorizes Texas school districts to obtain evidence that a person is eligible to attend the public schools of the district at the time of enrollment. To be eligible for continued enrollment in Responsive Education Solutions, the parent or guardian of a student must show proof of residency at the time of enrollment . To comply with residency requirements, the parent or guardian of a student must return this document to Responsive Education Solutions with an original of at least two of the following documents showing name and verifiable current address. (Documents showing evidence of any alteration will not be accepted.) Parent / Guardian must provide at least two (2) of the following documents: _______ Current Utility Bill in parent/guardian’s name

_______ Current Texas Driver’s License with current residential address

_______ Executed lease agreement

_______ Deed of Sale

____________________________________________ Signature of Parent or Guardian

________ Tax Statement

____________________________ Date

I affirm that I have seen and reviewed the verification of residency. _______________________________________, Signature of School Official

____________________________ Position

__________________________ Date

Photo / Video Release I, (Name of parent / guardian) _______________________________, do hereby give or grant permission to and assign all rights in and to any photographs, motion pictures, video footage, and/or audio recordings that may be taken of my child during his/her attendance at Responsive Education Solutions that may be used for promotional or training purposes. I hereby authorize the above-named entities to reproduce, copy, exhibit, publish, and distribute any and all photographs, motion pictures, video footage, and/or audio recordings for the sole purpose of promoting the RES learning system or training and professional development of staff. I certify that I am over the age of twenty-one (21). (Signed) ___________________________________________________ parent / guardian PLEASE NOTE: Signing this form is not a condition of enrollment. ResponsiveEd, however, greatly appreciates your cooperation.

Notice of Compulsory Attendance Law This notice is to advise you that according to Section 25.085 of the Texas Education Code, children between the ages of six (6) and their th 18 birthday are required to attend school on a daily basis unless specifically exempted by Section 25.086. A child who is required to attend school under this section shall attend school each day for the entire period the program of instruction is provided. The law places the responsibility on parents or those who stand in parental relationship to see that children attend school regularly. Any parent or person failing to require his child to attend school as required by law may be subject to a fine–an offense under this section is a Class C Misdemeanor and is punishable by a fine of UP TO $500 for each offense. Section 25.095 states that a parent will be notified in writing if a child is absent 10 days or parts of days during a six-month period or three (3) or more days or parts of days during a four-week period. Responsive Education Solutions will enforce these laws as stated by the Education Code and will report all offenses to the local authorities. By signing below I am acknowledging the receipt of this notification. A person who knowingly falsifies information on a form required for a student’s enrollment in Responsive Education Solutions shall be liable to RES if the student is not eligible for enrollment and is enrolled on the basis of false information. For the period in which the student is enrolled, the person is liable for the maximum tuition fee the District may charge or the amount the District has budgeted per student as maintenance and operating expense, whichever is greater. Texas Education Code § 25.031(g)

Student signature_______________________________________________________ Date____/ _____ / _____ (Custodial) Parent/Guardian signature ______________________________________ Date____ / _____ / _____ I affirm that I have seen and reviewed enrollment and residency information of the above student.

Registrar signature _____________________________________________________ Date____ / _____ / _____ 2013-14

AT-RISK INDICATORS/DOCUMENTATION Student Name ______________________________________________

Date __________________

A student at risk of dropping out of school includes each student who is under 21 years of age and who: (Check yes or no)

YES 

NO 





2. Is in grade 7, 8, 9, 10, 11, or 12 and did not maintain an average equivalent to 70 on a scale of 100 in two or more subjects in the foundation curriculum during a semester in the preceding or current school year or is not maintaining such an average in two or more subjects in the foundation curriculum in the current semester.





3. Was not advanced from one grade level to the next for one or more school years.





4. Did not perform satisfactorily on an assessment instrument [TAAS/TAKS] administered to the student under TEC Subchapter B, Chapter 39, and who has not in the previous or current school year subsequently performed on that instrument or another appropriate instrument at a level equal to at least 110 percent of the level of satisfactory performance on that instrument.





5. Is pregnant or is a parent.





6. Has been placed in an alternative education program in accordance with TEC §37.006 during the preceding or current school year.





7 Has been expelled in accordance with TEC §37.007 during the preceding or current school year.





8. Is currently on parole, probation, deferred prosecution, or other conditional release.





9. Was previously reported through the Public Education Information Management System (PEIMS) to have dropped out of school.





10. Is a student of limited English proficiency, as defined by TEC §29.052.





11. Is in the custody or care of the Department of Protective and Regulatory Services or has, during the current school year, been referred to the department by a school official, officer of the juvenile court, or law enforcement official.





12. Is homeless, as defined by 42 U.S.C. Section 11302, and its subsequent amendments; or





13. Resided in the preceding school year or resides in the current school year in a residential placement facility in the district, including a detention facility, substance abuse treatment facility, emergency shelter, psychiatric hospital, halfway house, or foster group home.





1. Is in prekindergarten, kindergarten or grade 1, 2, or 3 and did not perform satisfactorily on a readiness test or assessment instrument administered during the current school year.

The student is at-risk. (Check Yes or No)

Principal Signature: __________________________________________ Date: __________________________ Parent/Guardian Signature: ___________________________________ Date: __________________________ 2013-14

Texas Education Agency Texas Public School Student/Staff Ethnicity and Race Data Questionnaire The United States Department of Education (USDE) requires all state and local education institutions to collect data on ethnicity and race for students and staff. This information is used for state and federal accountability reporting as well as for reporting to the Office of Civil Rights (OCR) and the Equal Employment Opportunity Commission (EEOC). School district staff and parents or guardians of students enrolling in school are requested to provide this information. If you decline to provide this information, please be aware that the USDE requires school districts to use observer identification as a last resort for collecting the data for federal reporting. Please answer both parts of the following questions on the student’s or staff member’s ethnicity and race. United States Federal Register (71 FR 44866). Part 1. Ethnicity: Is the person Hispanic/Latino? (Choose only one.) Hispanic/Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race No Hispanic/Latino Part 2. Race: What is the person’s race? (Choose one or more.) American Indian or Alaska Native – A person having origins in any of the original peoples of North and South America (including Central America) and who maintains a tribal affiliation or community attachment Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam Black or African American – A person having origins in any of the black racial groups of Africa Native Hawaiian or Other Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands White – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa ________________________________

________________________________

Student/Staff Name (please print)

Parent or Guardian/Staff Signature

________________________________

________________________________

Student/Staff Identification number

Date

Texas Education Agency – March 2009

Home Language Survey Cuestionario del Idioma en el Hogar All questions must be answered completely. PLEASE PRINT Las preguntas deberán ser respondidas por completo. FAVOR ESCRIBIR EN LETRA DE MOLDE

Student / Estudiante___________________________________________________ Age / Edad __________ Campus / Escuela ____________________________________________________ Grade / Grado ________

Schools are required by Texas law to determine the following information for all students. Please help us meet this requirement by answering every question and signing and dating the form. A parent, guardian or student may sign when the student is in ninth grade or higher; otherwise, a parent or guardian must sign.

1. In what month and year did the student first enroll in a school in the United States? ___________ _________ Month

Year

2. In what city, state, and country was the student born? ____________________ ___________ ___________ City

State

Country

3. What language is spoken in your home most of the time?______________________________

4. What language does the student speak most of the time?______________________________

5. Does the parent of guardian need to communicate with the school in a language other than English? _______ If yes, write the name of the language. ________________________________________________________

OR… Bajo la Ley de Texas se requiere que las escuelas determinen la siguiente información por cada estudiante. Por favor, ayúdenos por contestar cada pregunta y por firmar y notar la fecha. Cuando el estudiante esté cursando el noveno grado o uno más alto, pueden firmar el padre, la madre, el guardián, o el estudiante. De otra manera, solamente pueden firmar los padres o los guardianes.

1. ¿En qué mes y año se inscribió el estudiante por primera vez en Los Estados Unidos? ___________ _________ Mes

2. ¿En qué ciudad, estado, y país nació el estudiante?

Año

____________________ ___________ ___________ Ciudad

Estado o provincia

País

3. ¿Cuál es el idioma que más se habla en su casa? ______________________________

4. ¿Cuál es el idioma que más habla el estudiante? ______________________________

5. Necesitará el padre, la madre, o el guardián comunicarse con la escuela utilizando un idioma que no sea el Inglés? Subraye la respuesta correcta. Sì No Si es así, favor escribir el nombre del idioma. __________________________________

Signature (Firma)_________________________________________ Date (Fecha)___________ 2013-14

School Year: 20___ - 20___

Occupational Survey Your Children May Be Eligible for Extra Services IMPORTANT: Please complete the survey below and return it to your school office. Name of Student_____________________________________________Grade________________ Within the past three (3) years, has your child(ren) traveled or moved alone with a parent, relative, guardian, or a spouse so that a family member could look for or do temporary or seasonal agricultural work or employment?

Yes ____ No ___

Signature of Parent/Guardian_____________________________ Date ___________________________

If No, please stop here and hand this survey back to your school district.

If YES, please () the type of employment and complete the following contact information below. ___a. Farming ___f. Picking fruit or vegetables ___l. Plant nursery ___b. Ranching ___g. Cotton farming/ginning ___m. Poultry production ___c. Fencing ___h. Combining/harvesting grain ___n. Clearing land ___d. Dairying ___i. Driving tractors, machinery ___o. Picking pecans, etc. ___e. Fishing ___j. Tree growing or harvesting ___p. Bailing hay ___k. Food processing in plants ___q. Other similar work

Contact Information Name of Child(ren)____________________________________________________________________ ___________________________________________________________________________________ Father/Guardian __________________________ Mother/Guardian______________________________ Home Address________________________________________________________________________ Street City State ZIP Home Phone (____) _________________________ Other Phone (____) __________________________ 2013-14

School Year: 20___ - 20__

Formulario De Trabajo Sus Hijos Podrían Recibir Servicios Extras IMPORTANTE: Por favor complete este formulario y regréselo a la escuela. Nombre de Estudiante ______________________________ Grado/Curso _________________ ¿Durante los últimos tres (3) años, viajó o se fue su hijo/a a vivir solo/a con sus padres, algún guardián legal, o esposo/a para que alguno de la familia buscara o encontrara trabajo temporal en la agricultura?

Sí ____ No ___

Firma de Padres/Guardían __________________________________Fecha _______________________

Si contestó No, no es necesario seguir completando este formulario. Sólo regréselo a la escuela, a la brevedad.

Si contestó Sí, por favor indique con un () y complete la siguiente información de contacto abajo. ___a. En la cosecha ___f. Recogiendo frutas/verduras ___l. En guardería de plantas ___b. En ranchos/ ___g. En el algodón ___m. En producción de aves ranchería ___h. Cosechando granos ___n. Limpiando terrenos ___c. En las cercas ___i. En el manejo de tractores, maquinaria ___o. Recogiendo nuez, etc. ___d. En lecherías ___j. Plantando árboles ___p. Recogiendo paja ___e. En la pesca ___k. Procesando comida en fábricas ___q. Algún otro trabajo similar

Referencia Hijo(s)______________________________________________________________________________ ____________________________________________________________________________________ Padre/Guardián ____________________________Madre/Guardián_____________________________ Domicilio____________________________________________________________________________ Calle Ciudad Estado ZIP Teléfono del hogar (____) _____________________ Otro teléfono (____) _________________________

2013-14

ESL PARENT PERMISSION LETTER I, _____________________________, (print name of parent/guardian) hereby give permission for my child, ________________________________, (print name of child) to receive extra help in English as a Second Language as part of a Responsive Education Solutions English as a Second Language (ESL) program if he/she is found to be limited in either oral or cognitive and academic English proficiency skills. If any language other than English is spoken at home, Responsive Education Solutions will evaluate my student’s oral English language skills with a short Oral Language Proficiency Test and his/her academic and cognitive English with a Norm-Referenced test of Language Arts and Reading skills as required by Texas State Law.

[Para aquellos que hablan Español (For those who speak Spanish):] Yo, _____________________________(nombre del padre, madre, o guardián) Doy permiso para que mi hijo/a ________________________________(nombre del niño/a) reciba instrucción en el Programa de Inglés como Segundo Idioma si en él/ella se encuentre una proficiencia limitada en el idioma de Inglés.

Please sign below (Favor de firmar abajo):

________________________________________________

____________________

Parent/Guardian Name (Nombre del Padre, Madre, o Guardián)

Date (Fecha)

_______________________________________________________ Parent/Guardian Phone Number (Número de teléfono del Padre, Madre, Guardián):

2013-14

STUDENT NAME: ___________________________________________________ DATE OF BIRTH: ________________________________

SPECIAL EDUCATION Was Student receiving Special Education services at the last school Student attended? Yes No Check One: If “Yes,” then please complete the following: Check all that apply: Content Mastery/Resource Room Counseling Speech Therapy Occupational/Physical Therapy Behavior Adjustment Class Other: Please Specify: What is Student’s disability? ___________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ If “No,” then please complete the following: Has Student ever received Special Education services? Check One:

Yes

No

If “Yes,” please specify school name, year, and disability/condition (if known): _____________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ __________________________________________________________________ ___________________________ Parent/Guardian Signature Date

 

 

201͵‐201Ͷ STUDENT ENROLLMENT PACKET



PAGE 5 OF 11

STUDENT NAME: ___________________________________________________ DATE OF BIRTH: ________________________________

SECTION 504 Was Student receiving Section 504 and/or Dyslexia services/accommodations at the last school Student Yes No attended? Check One: If “Yes,” then please complete the following: Check all that apply: Instructional Services Instructional Accommodations Testing/Assessment Accommodations Other: Please Specify: What is Student’s disability? ___________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ If “No,” then please complete the following: Has Student ever received Section 504 and/or Dyslexia services? Check One:

Yes

No

If “Yes,” please specify school name, year, and disability/condition (if known): _____________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ __________________________________________________________________ ___________________________ Parent/Guardian Signature Date

 

 

201͵‐201Ͷ STUDENT ENROLLMENT PACKET



PAGE 6 OF 11

STUDENT HEALTH HISTORY Date ____________________________ Student: __________________________________________________________ Phone # (_______) - _______ -_______ LAST

FIRST

MIDDLE

Social Security # ______ - _____ - ______ D.O.B. ____ /_____ /_______ Campus________________________________ Student resides with Parent(s) ____________________ Spouse ____________________ Other ______________________ NAME

NAME

NAME

Is student pregnant? Yes ___ No ___ If yes, expected due date ___ / ___ / ___ Doctor _____________________________ NAME AND PHONE #

Please list student allergies to medicine, food, environmental, or other that you are aware of or suspect: ___________________________________________________________________________________________________ Please identify if student has had the following diseases by writing the age he/she had the disease on the line: Chickenpox ________ Measles ________ Mumps ________ AGE

AGE

AGE

Please check any of the following illnesses, injuries, or conditions which student has had or currently has: PLEASE INDICATE IF IT IS A PAST OR PRESENT CONDITION / DOCTORS / CURRENT MEDICATION REQUIREMENTS AND PURPOSE. FAVOR DE INDICAR SI LA CONDICION ES PASADO O PRESENTE / DOCTORES / MEDICACION REQUIRIDO Y SU PROPOSITO.

___ Asthma or Lung Problems _________________________________________________________________ ASMA / PROBLEMAS DEL PULMON

___ Diabetes/Hepatitis _______________________________________________________________________ DIABETES / HEPATITIS

___ Ear/Nose/Throat _________________________________________________________________________ OIDO / NARIZ / GARGANTA

___ Epilepsy/Seizures________________________________________________________________________ EPILEPSIA / ATAQUES EPILEPTICOS

___ Fracture/Dislocation/Strain _________________________________________________________________ FRACTURAS / LUXACIONES

___ Hearing Aid/Orthopedic Braces _____________________________________________________________ APARATO AUDITIVO / ORTHOPEDICO

___ Head Injury _____________________________________________________________________________ GOLPES DE LA CABEZA

___ Heart Problems __________________________________________________________________________ PROBLEMAS DEL CORAZON

___ Kidney Problems _________________________________________________________________________ PROBLEMAS DEL RINON

___ Ulcers/Digestive _________________________________________________________________________ ULCERAS / PROBLEMAS DIGESTIVOS

___ Skin/Toes ______________________________________________________________________________ PROBLEMAS DE LA PIEL

___ Surgery ________________________________________________________________________________ CIRUGIAS

___ Other: i.e., ADHD/AIDS etc. _________________________________________________________________ OTRAS PROBLEMAS: EJEMPLO, PROBLEMAS CON ATENCION A SIDAS, ETC.

Is student currently under the care of a doctor for any problem not discussed above? Please provide details on back. SI ESTA RECIBIENDO ATENCION MEDICA POR QUALQUIER OTRA RAZON, FAVOR INDICAR CON QUIEN Y PARA QUE. NECESITAMOS LOS DETALLES.

2013-14

STATE COMPENSATORY EDUCATION ALLOTMENT 2012-2013 ELIGIBILITY GUIDELINES Please circle one number in the “Family Size” column, and only one income amount on that same row. This information will assist us to provide additional materials, computer hardware, and telecommunications and Internet service for our students. Thank you for your assistance.

Family Size

If your income is annual, please use the amounts below.

If your income is monthly, please use the amounts below.

If your income is twice per month, please use the amounts below.

If your income is every two weeks, please use the amounts below.

Less than the following annual amount:

Less than the following monthly amount:

Less than the following twice per month amount:

Less than the following two-week amount:

1

$14,521

$20,665

$1,211

$1,723

$606

$862

$559

$795

2

$19,669

$27,991

$1,640

$2,333

$820

$1,167

$757

$1,077

3

$24,817

$35,317

$2,069

$2,944

$1,035

$1,472

$955

$1,359

4

$29,965

$42,643

$2,498

$3,554

$1,249

$1,777

$1,153

$1,641

5

$35,113

$49,969

$2,927

$4,165

$1,464

$2,083

$1,351

$1,922

6

$40,261

$57,295

$3,356

$4,775

$1,678

$2,388

$1,549

$2,204

7

$45,409

$64,621

$3,785

$5,386

$1,893

$2,693

$1,747

$2,486

8

$50,557

$71,947

$4,214

$5,996

$2,107

$2,998

$1,945

$2,768

$306

$198

$282

For each additional family member add:

$5,148

$7,326

$429

$611

$215

If your family income is greater than those listed above, please indicate here: My family income is greater than those listed above.  (Please check box) If you wish, circle the correct response:

Do you receive Food Stamps?

Yes

No

Please sign below:

________________________________________________ Parent/Guardian Name (Signature)

________________________________________________ Student Name (Printed)

____________________ Date

____________________ Grade Level

2012-2013

STUDENT RECORD RELEASE DATE ____________________

To Releasing School Counselor or Registrar:

School Name:

_________________________________________________

School Address:

_________________________________________________

City, State, Zip:

_________________________________________________

School Telephone:

(______)_______________

Fax Number:

(______)_______________

The following student has withdrawn from your school. _____________________________

_________________

______________________

Student

Date of Birth

Student ID #

Please forward the following information on the above student: ___ Official Transcript

___ Academic Records

___ Testing Scores/Assessment

___ Health Records

___ Special Ed Classification / Documents ___ Copy of Social Security Card

504 Evaluation and Plan ___ Copy of Birth Certificate

Copy of Original Home Language Survey and LPAC records ___ Other Please respond to the following address: Texas Virtual Academy Attn: Student Records Dept. 1800 Lakeway Drive, Suite 100 Lewisville TX, 75057 972.420.1404 – Office 888.506.6777 – Fax

__________________________________ Signature of Guardian or Registrar

___________________ Date

2013-14

EMERGENCY INFORMATION

________________________________________ Student’s Name (PRINTED)

______________________ Date of Birth

In case the services of a physician are required before parent/guardian can be reached, the school officials of Responsive Education Solutions are hereby authorized to take whatever action is deemed necessary for the health of my child. I also authorize ResponsiveEd school officials to directly contact the physician named below in case of an emergency.

I will not hold Responsive Education Solutions or its staff responsible for emergency care and/or transportation for my child, and I will assume responsibility for any costs related to such services provided to my child.

Physician’s Name: _______________________________________________________ Physician’s Phone Number: ________________________________________________ Emergency Contact Person (other than parent/guardian): ______________________________________________________________________ Emergency Contact Person’s Telephone Number: ______________________________________________________________________

I also hereby give ResponsiveEd faculty/staff permission to give the following medication to my child as indicated below. (Examples: Tylenol or acetaminophen 200 mg for headache, Ibuprofen 200 mg for headache, etc.)

Medication & Dosage: ______________________________________________________________________ Medication & Dosage: ______________________________________________________________________

________________________________________ Parent/Guardian Signature

Date: _____________________ 2013-14

Verification of Enrollment Must be completed by previous school personnel only Texas Virtual Academy Information as Reported to PID Student Legal Name: First Student SSN or State ID:

Middle

____________________

Last

DOB:   _________________      Grade:  ___________

RECEIVING SCHOOL ‐‐ PLEASE COMPLETE THE INFORMATION BELOW: Above Student Enrolled On:

_______   Above Student Did Not Enroll

Above Student Enrolled, but has withdrawn.  Enrollment Date:     _____________

School Name:

Withdraw Date:   _______________

School Official:

Address: Signature

Telephone:

Today's Date

Is student enrolled at this school under a different name? Yes

No

Yes

No

Yes

No

If yes, indicate name: Is student enrolled at this school under a different SSN or State ID? If yes, indicate number: Is student enrolled at this school under a different date of birth? If yes, date of birth:

PLEASE FAX INFORMATION TO TEXAS VIRTUAL ACADEMY Registrar Texas Virtual Academy 1800 Lakeway Drive, Ste 100 Lewisville, TX  75057

Phone:     (972) 420‐1404 Fax:            (888) 506‐6777

2012-2013 Texas Minimum State Vaccine Requirements for Students Grades K-12 This chart summarizes the vaccine requirements incorporated in the Texas Administrative Code (TAC), Title 25 Health Services, Sections 97.61 to 97.72. This chart is not intended as a substitute for consulting the TAC, which has other provisions and details. Click here for complete TAC language. The Department of State Health Services (DSHS) is granted authority to set immunization requirements by the Texas Education Code, Chapter 38, Health & Safety, Subchapter A, General Provisions.

IMMUNIZATION REQUIREMENTS A student shall show acceptable evidence of vaccination prior to entry, attendance, or transfer to a child-care facility or public or private elementary or secondary school in Texas. Vaccine Required (Attention to notes and footnotes)

Minimum Number of Doses Required by Grade Level K - 3rd 4th- 6th 7th 8th - 10th 11th - 12th

5 doses or 4 doses

3 dose primary series and 1 Tdap/Td booster within last 5 years

4 doses or 3 doses

4 doses or 3 doses

5 doses or 4 doses

Diphtheria/Tetanus/Pertussis (DTaP/DTP/DT/Td/Tdap)1

1

Polio

4 doses or 3 doses

Measles, Mumps, and Rubella1,2 (MMR)

2 doses

2 doses

Hepatitis B2

3 doses

3 doses

Varicella1,2,3

2 doses

Meningococcal Hepatitis A1,2 1

1 dose

3 dose primary series and 1 Tdap/Td booster within last 10 years

4 doses or 3 doses

2 doses

3 doses

3 doses

2 doses

4 doses or 3 doses

NOTES 5 doses of diphtheria-tetanus-pertussis vaccine; one dose must have been received on or after the 4th birthday. However, 4 doses meet the requirement if the 4th dose was received on or after the 4th birthday. For students aged 7 years and older, 3 doses meet the requirement if one dose was received on or after the 4th birthday. For 7th grade: 1 dose of Tdap is required if at least 5 years have passed since the last dose of tetanus- containing vaccine. For 8th- 12th grade: 1 dose of Tdap is required when 10 years have passed since the last dose of tetanus-containing vaccine. Td is acceptable in place of Tdap if a medical contraindication to pertussis exists. 4 doses of polio; one dose must be received on or after the 4th birthday. However, 3 doses meet the requirement if the 3rd dose was received on or after the 4th birthday.

2 doses

The first dose of MMR must be received on or after the 1st birthday. For K - 3rd grade, 2 doses of MMR are required. For 4th - 12th grade, 2 doses of a measles-containing vaccine, and one dose each of rubella and mumps vaccine is required.

3 doses

For students aged 11-15 years, 2 doses meet the requirement if adult hepatitis B vaccine (Recombivax) was received. Dosage and type of vaccine must be clearly documented. (Two 10 mcg/1.0 ml of Recombivax).

1 dose

The first dose of varicella must be received on or after the first birthday. For grades K – 3rd and 7th - 10th 2 doses are required. 1 dose is required for all other grade levels. For any student who receives the first dose on or after 13 years of age, 2 doses are required.

1 dose 2 doses

The first dose of hepatitis A must be received on or after the first birthday.

Receipt of the dose up to (and including) 4 days before the birthday will satisfy the school entry immunization requirement. Serologic confirmation of immunity to measles, mumps, rubella, hepatitis B, hepatitis A, or varicella or serologic evidence of infection is acceptable in place of vaccine. 3 Previous illness may be documented with a written statement from a physician, school nurse, or the child's parent or guardian containing wording such as: "This is to verify that (name of student) had varicella disease (chickenpox) on or about (date) and does not need varicella vaccine." This written statement will be acceptable in place of any and all varicella vaccine doses required. 2

Exemptions The law allows (a) physicians to write a statement stating that the vaccine(s) required would be medically harmful or injurious to the health and well-being of the child or household member, and (b) parents/guardians to choose an exemption from immunization requirements for reasons of conscience, including a religious belief. The law does not allow parents/guardians to elect an exemption simply because of inconvenience (for example, a record is lost or incomplete and it is too much trouble to go to a physician or clinic to correct the problem). Schools and child-care facilities should maintain an up-to-date list of students with exemptions, so they may be excluded in times of emergency or epidemic declared by the commissioner of public health. Instructions for requesting the official exemption affidavit that must be signed by parents/guardians choosing the exemption for reasons of conscience, including a religious belief, can be found at www.ImmunizeTexas.com. Original Exemption Affidavit must be completed and submitted to the school or child-care facility. For children claiming medical exemptions, a written statement by the physician must be submitted to the school or child-care facility. Provisional Enrollment All immunizations should be completed by the first date of attendance. The law requires that students be fully vaccinated against the specified diseases. A student may be enrolled provisionally if the student has an immunization record that indicates the student has received at least one dose of each specified age-appropriate vaccine required by this rule. To remain enrolled, the student must complete the required subsequent doses in each vaccine series on schedule and as rapidly as is medically feasible and provide acceptable evidence of vaccination to the school. A school nurse or school administrator shall review the immunization status of a provisionally enrolled student every 30 days to ensure continued compliance in completing the required doses of vaccination. If, at the end of the 30-day period, a student has not received a subsequent dose of vaccine, the student is not in compliance and the school shall exclude the student from school attendance until the required dose is administered. Documentation Since many types of personal immunization records are in use, any document will be acceptable provided a physician or public health personnel has validated it. The month, day, and year that the vaccination was received must be recorded on all school immunization records created or updated after September 1, 1991.

Texas Department of State Health Services • Immunization Branch • MC-1946 • P O Box 149347 • Austin, TX 78714-9347 • (800) 252-9152 Stock# 6-14

Rev. 01/24/2012

Requisitos de vacunación mínimos estatales de Texas de 2012-2013 para estudiantes de kínder-12.o grado Este gráfico resume los requisitos de vacunación incorporados en el Código Administrativo de Texas (o TAC), título 25, Servicios de salud, Secciones 97.61 a 97.72. El gráfico no tiene como propósito sustituir las consultas al TAC, el cual contempla otras disposiciones y detalles. Haga clic aquí para obtener el texto completo del TAC. El Código Educativo de Texas, capítulo 38, Salud y Seguridad, subcapítulo A, Disposiciones Generales, concede la autoridad de establecer requisitos de inmunización al Departamento Estatal de Servicios de Salud de Texas (o DSHS).

REQUISITOS DE INMUNIZACIÓN Los estudiantes deberán mostrar comprobantes de vacunación aceptables antes de entrar, asistir o ser transferidos a una guardería o escuela primaria o secundaria pública o privada de Texas. Vacuna requerida

Número mínimo de dosis requeridas por nivel de grado

(Vea las notas y las notas de pie de página)

Kínder - 3.o 4.o - 6.o

8.o - 10.o 11.o - 12.o

Difteria, tétanos y pertusis (DTaP, DTP, DT, Td, Tdap)1

5 dosis o 4 dosis

Serie primaria Serie primaria de 3 de 3 dosis y 1 dosis y 1 dosis de dosis de 5 dosis o refuerzo de la refuerzo de la 4 dosis vacuna Tdap o Td vacuna Tdap o en los últimos 10 Td en los años últimos 5 años

Polio1

4 dosis o 3 dosis

4 dosis o 3 dosis

1,2

Sarampión, paperas y rubéola (MMR)

2 dosis

2 dosis

2

Hepatitis B

3 dosis

3 dosis

Varicela1,2,3

2 dosis

1 dosis

Meningocócica 1,2

Hepatitis A 1

7.o

4 dosis o 3 dosis

4 dosis o 4 dosis o 3 dosis 3 dosis

2 dosis

3 dosis

2 dosis

2 dosis

3 dosis

3 dosis

1 dosis

NOTAS 5 dosis de la vacuna contra la difteria, el tétanos y la pertusis; debe haberse recibido una dosis en o después del 4.o cumpleaños. Sin embargo, con 4 dosis se cumple con el requisito si la 4.a dosis se recibió en o después del 4.o cumpleaños. Los estudiantes de 7 años de edad o más, con 3 dosis cumplen con el requisito si recibieron una dosis en o después del 4.o cumpleaños. Para el 7.o grado: se requiere 1 dosis de la vacuna Tdap si han pasado al menos 5 años desde la última dosis de una vacuna que contenga tétanos. Para los grados de 8.o-12.o: se requiere 1 dosis de la vacuna Tdap si han pasado 10 años desde la última dosis de una vacuna que contenga tétanos. La vacuna Td es aceptable en lugar de la vacuna Tdap si existe una contraindicación médica con respecto a la vacuna contra la pertusis. 4 dosis de la vacuna contra la polio; debe recibirse una dosis en o después del 4.o cumpleaños. Sin embargo, con 3 dosis se cumple con el requisito si la 3.a dosis se recibió en o después del 4.o cumpleaños. La primera dosis de la vacuna MMR debe recibirse en o después del 1.er cumpleaños. Para el kínder-3.er grado, se requieren 2 dosis de la vacuna MMR. Para los grados de 4.o-12.o, se requieren 2 dosis de una vacuna que contenga sarampión, y una dosis de la vacuna contra la rubéola y una de la vacuna contra las paperas. Los estudiantes de 11-15 años de edad, con 2 dosis cumplen con el requisito si recibieron la vacuna contra la hepatitis B para adultos (Recombivax). Deben documentarse claramente la dosis y el tipo de vacuna. (Dos dosis de 10 mcg/1.0 ml de Recombivax). La primera dosis de la vacuna contra la varicela debe recibirse en o después del 1.er cumpleaños. Para el kínder-3.er y 7.o-10.o grado, se requieren 2 dosis. Se requiere 1 dosis para todos los demás niveles de grado. Se requieren 2 dosis para todos los estudiantes que reciban la primera dosis en o después de los 13 años de edad.

1 dosis 2 dosis

La primera dosis de la vacuna contra la hepatitis A debe recibirse en o después del 1.er cumpleaños.

Recibir la dosis hasta (e inclusive) 4 días antes del cumpleaños satisfará el requisito de inmunización para entrar a la escuela. La confirmación serológica de la inmunidad al sarampión, las paperas, la rubéola, la hepatitis B, la hepatitis A o la varicela o la evidencia serológica de infección son aceptables en lugar de la vacuna. 3 La enfermedad previa puede documentarse con una declaración escrita de un médico, una enfermera escolar o el padre o tutor del niño que diga algo como: "Esto es para verificar que (nombre del estudiante) tuvo varicela el (fecha) o por esa fecha y no necesita la vacuna contra la varicela". Dicha declaración escrita será aceptable en lugar de todas las dosis requeridas de la vacuna contra la varicela. 2

Exenciones La ley permite que (a) los médicos redacten una declaración en la que expongan que la vacuna o vacunas requeridas serían médicamente dañinas o perjudiciales para la salud y el bienestar del niño o de una persona que vive en la casa y que (b) los padres o tutores elijan una exención de los requisitos de inmunización por razones de conciencia, incluso creencias religiosas. La ley no permite que los padres o tutores elijan una exención simplemente por inconveniencia (por ejemplo, si se pierde un registro o éste está incompleto y sería mucha molestia ir con un médico o clínica para corregir el problema). Las escuelas y las guarderías deben mantener una lista actualizada de los estudiantes con exenciones, de forma que se les pueda excluir durante emergencias o epidemias declaradas por el director de salud pública. Encontrará instrucciones para solicitar la declaración jurada de exención oficial que debe ser firmada por los padres o tutores que elijan la exención por razones de conciencia, incluso creencias religiosas, en www.ImmunizeTexas.com. La declaración jurada de exención original debe rellenarse y presentarse a la escuela o guardería. En el caso de los niños que soliciten exenciones médicas, deben presentar una declaración escrita del médico a la escuela o guardería. Inscripción provisional Todas las inmunizaciones se deben finalizar antes de la primera fecha de asistencia. La ley exige que los estudiantes estén completamente vacunados contra las enfermedades señaladas. Un estudiante se puede inscribir provisionalmente si el estudiante cuenta con registro de inmunización que indique que el estudiante ha recibido al menos una dosis de cada vacuna apropiada para la edad específica que esta regla exija. Para seguir inscrito, el estudiante debe completar las dosis posteriores requeridas de cada serie de vacunas conforme al calendario y tan rápidamente como sea médicamente posible y proveer comprobante suficiente de la vacunación a la escuela. Una enfermera escolar o un administrador escolar revisará el estado de inmunización de un estudiante inscrito provisionalmente cada 30 días para garantizar el cumplimiento ininterrumpido en la finalización de las dosis de vacunas requeridas. Si, al final del periodo de 30 días, un estudiante no ha recibido una dosis posterior de la vacuna, el estudiante no está cumpliendo y la escuela excluirá al estudiante para que no asista a la escuela hasta que se administre la dosis requerida. Documentación Dado que se usan muchos tipos de registros de inmunización personales, cualquier documento es aceptable si un médico o el personal de salud pública lo ha validado. Debe registrarse el mes, día y año en que se recibió la vacuna en todos los registros de inmunización escolares creados o actualizados después del 1 de septiembre de 1991.

Texas Department of State Health Services • Immunization Branch • MC-1946 • P O Box 149347 • Austin, TX 78714-9347 • (800) 252-9152 Stock No. 6-14

Rev. 01/24/ 2012