Enrollment Package 2015-2016 Pre-Kindergarten Only Student Name: Last First Middle Once qualified for the Pre-K program, to officially apply for enrollment, all documents/actions listed below must be completed and/or submitted. Forms in this application to be completed by Parents/Students and returned: 1 Student Enrollment Information 2 Emergency Physician and Care Authorization 3 Food Allergy Information 4 Lottery System Acknowledgement 5 Enrollment Verification 6 Parent/Student Handbook & Code of Conduct Acknowledgement 7 Release of Liability for Field Trips/Physical Fitness/Survey/Photo Release 8 Military Connected/Foster Care Questionnaire 9 Family Survey 10 Student Residency Questionnaire 11 Ethnicity and Race Data Questionnaire 12 Home Language Survey Documentation that needs to be turned in with application: 1 Proof of Residency (Utility, Telephone, or Property Tax Bills; Driver license is not acceptable) 2 Copy of Social Security Card (This disclosure is voluntary and the SS# is used for student ID in PEIMS) 3 Copy of Proof of identity (birth records, driver's license, passport, military id, transcripts, report card, adoption record) 4 Shot Records indicating current immunizations 5 Proof of Guardianship, if applicable (if student does not live with parents) Final steps for registration: 1 Schedule and complete an interview with SWPS administrator (if this is your first enrollment) Revised March 2015 SWPS Registration Application 1
Revised March 2015 SWPS Registration Application 2
of Enrollment / / 1 Student Enrollment Information Section I: Student Applicant Information Student Name: First Name MI Last Name SSN#/State ID: Current Grade Level: _Pre-K Student Address: City: State: Zip: County: Home Phone #: Alternate Phone #: of Birth: Birth Place: Were you referred to Southwest Preparatory? No Yes, If yes, by whom: If you were not referred to SWP, how did you hear about us? SWPrep Facebook Page Other Internet Website Newspaper Radio Previous School Street Banner Summer Camp Television Business Twitter Other (please specify) Section II: Student Parent Guardian Information Student Lives With: Father and Mother Stepfather and Mother Stepmother and Father Father Only Mother Only Stepfather Stepmother Grandfather Grandmother Uncle Aunt Cousin Friend Self-Sufficient Guardian(s) Relation: Other 1st Parent/Guardian: 2nd Parent/Guardian First, Last Name (1 st Parent is always the parent enrolling student) First, MI, Last Name 1st Prnt/Grdn Relationship: 2nd Prnt/Grdn Relationship: 2 nd Prnt/Grdn Address: 1st Prnt/Grdn Home Phone #: 2nd Prnt/Grdn Home Phone #: 1st Prnt/Grdn Work Phone #: Ext: 2nd Prnt/Grdn Work Phone #: 1st Prnt/Grdn Cell/Pager #: 2nd Prnt/Grdn Cell/Pager #: 1st Prnt/Grdn-DriverLic#/Issuing State/SSN#/DOB: / / / In order to more efficiently communicate with parents/guardians, we would appreciate the opportunity to use e- mail when possible. Do you have a home e-mail address? Yes No Would you like access to our Parent Portal? Yes No What is your e-mail address? May the school communicate with you by means of e-mail (regular mailings will continue)? Yes No Revised March 2015 SWPS Registration Application 3
Section III: Student School History Information Resident School: Resident ISD School District: Please note the school/ school district in which the student lives. The school/school district a student resides in is sometimes called the Home District.. Section IV: Emergency Contacts: 1st Emergency Contact: 2nd Emergency Contact: 1st Contact Relationship: 2nd Contact Relationship: 1st Contact Home Phone: 2nd Contact Home Phone: 1st Contact Work Phone: 2nd Contact Work Phone: **Emergency contact information will be verified before enrollment Section V; Authorized Pick Up The below listed person are authorized to pick up this student from school: Name: Relationship: Phone Number: Name: Relationship: Phone Number: Name: Relationship: Phone Number: Parent Signature: : Student Signature: : Revised March 2015 SWPS Registration Application 4
2 Emergency Physician and Care Authorization Student Name (Last) (First) (MI) Sex Grade of Birth Home Address Zip Home Phone Father s/guardian s Name Business Name & Address Business Phone Mother s/guardian s Name Business Name & Address Business Phone Student Lives With: Both Parents Mother only Father only Other (specify) If parents cannot be contacted please indicate alternate adult(s) whom the school should call. Please indicate relationship (e.g. neighbor, grandparents, etc.) Alternate Adult Relationship Address Phone Alternate Adult Relationship Address Phone Current Health Problems: (Check All That Apply) Cardiac Asthma Diabetes Seizure Disorder Blood Disorder Other Severe Drug Allergy Name Of Drug And Reaction Is Breathing Affected? Yes No Severe Food Allergy Name Of Food & Reaction Is Breathing Affected? Yes No Severe Insect Bite Allergy Name Of Insect & Reaction Is Breathing Affected Yes No Vision Problem Type Glasses Or Contacts? Yes No Hearing Problem Type/Cause_ Hearing Aid Appliance? Yes No Hearing Loss: Permanent Temporary Past Health Problems: (Check All That Apply) Chicken Pox Hepatitis A B Other Mononucleosis Surgery (Describe) Other: Medications Taken On A Regular Basis: Other Health Problems/Concerns: of Last Tetanus Booster: NOTE: PLEASE INITIAL HERE IF THERE ARE NO HEALTH PROBLEMS: Physician Phone Dentist Phone SWPS does not assume any financial responsibility but does wish to provide the best emergency service. By signing this form you are giving school personnel authority to call EMS or to obtain medical care if you or the alternate adults cannot be reached and releasing SWPS and its staff from any financial responsibility. I hereby grant permission for emergency medical care to be given by the attending physician and/or school personnel. I also give permission for EMS to be called and for my child to be transported as necessary by school or EMS personnel to the nearest hospital. Under the law, it is the parent/guardians responsibility to update the school with current address and contact information. Signature of Parent/Guardian Revised March 2015 SWPS Registration Application 5
3 Food Allergy Information This form allows you to disclose whether your child has a food allergy or severe food allergy that you believe should be disclosed to the District in order to enable the District to take necessary precautions for your child s safety. Severe food allergy means a dangerous or life-threatening reaction of the human body to a food-borne allergen introduced by inhalation, ingestion, or skin contact that requires immediate medical attention. Please list any foods to which your child is allergic or severely allergic, as well as how your child reacts when exposed to the food that is listed. The campus will contact you for more information as needed. No information to report Food Nature of Allergic Reaction to Food Life-Threatening? The district will maintain the confidentiality of the information provided above and may disclose the information to teachers, school counselors, school nurses, and other appropriate school personnel only within the limitations of the Family Educational Rights and Privacy Act and District policy. The district will maintain this form as part of your child s student record. Student name: of Birth: Grade: School: Parent/Guardian Name: Work Phone: Mobile Phone: Home phone: Parent/Guardian Signature : form received by School Campus: Revised March 2015 SWPS Registration Application 6
Dear Student/Parent/Guardian: 4 Lottery System Acknowledgement Lottery System (SWPS) is an open-enrollment charter school which utilizes a lottery system for enrollment. A lottery is a random selection process that determines the order of enrollment of student applicants. A lottery is to be conducted if the number of applicants exceeds the maximum enrollment or if classes are oversubscribed during the application period at any campus. The lottery shall take place within fifteen days after the closing date of the application period. The principal of each campus will supervise the lottery and shall post the results immediately after completion. The public is invited to watch the lottery. Development of Waiting Lists Once all openings have been filled through the lottery system for the oversubscribed classes or campuses, the drawing will continue and randomly selected numbers will be used to create a waiting list. As space becomes available, applicants will be called from the waiting list beginning with the lowest number. Applicants selected by lottery will be admitted and will be enrolled. Admission Process of Returning Students Returning students (students who currently attend SWPSD and intend to return the next school year) are exempted from the lottery if they notify SWPSD of their intent to return the next school year by the end of the pre-enrollment period. Applications Submitted Outside the Designated Application Period If a student applies to SWPSD outside of the designated application period, the student will be placed on a waiting list in the order of the date in which the application is received. Students applying for admission in classes undersubscribed or campuses with openings will be admitted on a first-come-firstserve basis. Please complete the Acknowledgment section of this letter below. Thank you for complying with the Lottery System. Sincerely, Administration Acknowledgement: I hereby acknowledge that I have read and understand the SWPS Lottery System. Print Student s Full Name Student s Signature Print Parent/Guardian Full Name Parent/Guardian Signature Revised March 2015 SWPS Registration Application 7
5 Enrollment Verification is an open-enrollment charter school. The charter, awarded by the Texas Education Agency, governs the operation of the school. The provisions of the charter stipulate that as an open-enrollment charter school, will serve the following student population. 1. Students who are at least 3 years old or have not reached their 26 th birthday by September 1. 2. Any eligible student who resides within the boundaries of Bexar County may enroll as well as any student whose home district is in Boerne ISD, Charlotte ISD, Comal ISD, Comfort ISD, Devine ISD, D Hanis ISD, Floresville ISD, Hondo ISD, Navarro ISD, New Braunfels ISD, Pleasanton ISD, Poteet ISD, Poth ISD, Schertz-Cibolo-Universal City ISD, Seguin ISD, and Stockdale ISD. 3. Students who are 17 years of age, or older, and who are considered school dropouts at the time of enrollment must have earned a minimum of 17 academic credits before being enrolled as a student. Students who are 17 years of age or older, a dropout at time of enrollment, and have not earned 17 academic credits must complete their GED prior to enrolling into the diploma program. 4. Students expelled from other public schools and assigned to JJAEP as part of the terms of that expulsion may not enroll at SWPS until completion of the JJAEP assignment. 5. All students serving or scheduled to serve in an alternative education setting from their previous school must complete their assignment prior to enrolling at SWPS. My signature attests that I meet all the requirements for enrolling at SWPS. I have read and clearly understand the requirements listed above. I understand that my enrollment may be terminated if it is found that I have misrepresented any enrollment criteria. Student Signature Student of Birth Parent Signature Please complete the following information if you are an adult student (18 or older): 1. I authorize the following parent(s) / guardian(s) to review my educational records: Print Parent Name(s): 1. 2. 3. 4. Student Signature OR 2. I do not authorize my parent(s) / guardian(s) to review my educational records. Student Signature Revised March 2015 SWPS Registration Application 8
6 Parent/Student Handbook & Code of Conduct Acknowledgement Dear Student/Parent/Guardian: The Trustees officially adopted the Parent/Student Handbook & Code of Conduct to promote a safe and orderly learning environment for every student. Students and parents are required to read and discuss the Handbook. Our handbook is available on our website at www.swprep.org. If you do not have access to the internet, you may review the handbook in the Front Office of your student s campus, or we can provide you with a printed copy. Questions about the rules and consequences may be referred to the student s teacher, the school counselor, or the campus administrators for clarification or more detailed explanation. Students and parents are required to sign this letter below acknowledging receipt and willingness to comply with the school rules and policies as established by the Parent/Student Handbook & Code of Conduct. Please note that there may be exceptions to the Code of Conduct for students with disabilities whose ARD committee determines that the code is inappropriate due to the specific disability(ies) of the student. Sincerely, Administration We acknowledge that we have received a copy of the Parent/Student Handbook & Code of Conduct, and that we have read, discussed, and agree to comply with the rules and policies established therein. Print Student Full Name Student Signature Print Parent/Guardian Full Name Parent/Guardian Signature Revised March 2015 SWPS Registration Application 9
7 Release of Liability Form - Field Trip/ Physical Fitness Activities/Photographs/Surveys I,, the undersigned parent f, Print Parent/Guardian s Full Name Print Student s Full Name a resident of the City of, County of, State of Texas, do hereby authorize my child to participate in (SWPS) Physical Fitness/ Field Trip Activities/Surveys/Photos. I agree to release and discharge SWPS, its staff members, and all others who may be held liable from all claims, present and future, known or unknown, arising from my child s participation in school physical fitness and field trip activities for the duration of their time enrolled with Southwest Preparatory. I acknowledge that my child has no medical limitations and is fully capable of participating in said activities. I appoint SWPS to act on my behalf in the event that my child should require emergency medical attention while participating in a field trip or physical fitness activities. This appointment gives SWPS the authority to sign releases to physicians who may render medical care if it becomes necessary in case of an emergency. I agree to assume liability for payment of all professional services and to reimburse SWPS for any expense that it may incur resulting from any medical services for my child. I hereby agree to hold SWPS, SWPS employees, and any other agent of SWPS who may act on behalf of SWPS, harmless of any decision and any injury resulting from such decision concerning the care and treatment of my child. I agree that if my child s behavior is such that it disrupts or endangers the welfare of others, SWPS has my permission to deny him/her participation in such activities. All rules and standards in the student Code of Conduct apply while on school sponsored activities. I understand that, teachers and staff may take pictures of my child while engaged in various aspects of our programs. These pictures may be displayed on the walls in the classroom, on bulletin boards, in a newsletter, in marketing publications, on the school s website (www.swprep.org), and in the local newspaper. My signature below indicates my permission to photograph my child and use the photo or other digital reproduction of him/her for the publication process, whether electronic, print, or digital. Printed Name of Parent or Guardian Signature of Parent or Guardian Revised March 2015 SWPS Registration Application 10
8 Military Connected/Foster Care Questionnaire Student Name: The Texas Education Agency requires all local education agencies to collect specific data for state reporting. Please check the appropriate box in each category. Military Connectedness Not a military connected student. Student is a dependent of a member of the Army, Navy, Air Force, Marine Corps, or Coast Guard on Active duty. Student is a dependent member of the Texas National Guard (Army, Air Guard, or State Guard) Student is a dependent of a member of the reserve force in the United States military (Army, Navy, Air Force, Marine Corps, or Coast Guard) Pre-Kindergarten student is a dependent of 1) active duty uniformed member of the Army, Navy, Air Force, Marine Corps, or Coast Guard, 2) activated/mobilized uniformed member of the Texas National Guard (Army, Air Guard, or State Guard), or 3) activated/mobilized members of the Reserve components of the Army, Navy, Marine Corps, Air Force, or Coast Guard, who are currently on active duty or who were injured or killed while serving on active duty. Foster Care Student in not currently in the conservatorship of the Department of Family and Protective Services. Student is currently in the conservatorship of the Department of Family and Protective Services. Pre-Kindergarten student was previously in the conservatorship of the Department of Family and Protective Services following an adversary hearing help as provided by Section 262.201, Family Code. Print Parent/Guardian Full Name Parent/Guardian Signature PEIMS Coding For Office Use Only Military Connected 1-Active Duty 2-National Guard 3-Reserves 4-Pre-Kindergarten Foster Care 1-Foster Care 2-Foster Care-PK Foster Care/Military Connected Liaison Signature Revised March 2015 SWPS Registration Application 11
2015-2016 Family Survey 9 : District: Campus: Student Name: of Birth: Grade Level: Dear Parents, In order to better serve your children, our school district is helping the State of Texas identify students who may qualify to receive additional educational services. Please answer the following questions and return this form to your child s school. The information provided below will be kept confidential. 1. Within the past 3 years have you, or your child, moved from one school district, city or state to another? YES or NO 2. If yes, did you, or your child, move so you could work or look for work in agriculture or fishing? NO (STOP here and return survey to your child s school.) YES (Please check all that apply below) Fruit, vegetables, sunflower, cotton, wheat, grain, on farms or ranches, fields & vineyards Working in a cannery Working on a dairy farm or ranch. Working in a fishery Working on a poultry farm Working in a plant nursery, orchard, tree growing or harvesting Working in a slaughterhouse Other similar work, please explain: Please complete the following information: (Please print) Best time to contact you: Parent/Guardian Name: Home Address/Apt Name: City: Zip Code: Telephone Number: Mailing Address: City: Zip Code: Revised March 2015 SWPS Registration Application 12
10 Student Residency Questionnaire Name of Student: Sex: Male Female of Birth: / / Age: Social Security Number: 1. Is your current address a temporary arrangement? Yes No If you answered YES to the above questions, please complete the remainder of this form. If you answered NO, then stop here. Where is the student presently living? Please check the appropriate box. Caregiver(s) who are not legal guardians (Example: friends, relatives, parents of friends, etc.) In a motel In a shelter Moving from place to place In a place not designed for ordinary sleeping accommodations such as s car, park, or campsite Foster Care Other Name of Person student resides with: Address: City: Zip: Home Phone #: Cell Phone #: Other Phone #: Presenting a false record or falsifying records is an offense under Section 37.10, Penal Code, and enrollment of the child under false documents subjects the person to liability for tuition or other costs. Signature of Parent/Legal Guardian/Caregiver/Unaccompanied Student For School Use Only PEIMS Coding Homeless Status 1-Sheltered 2-Doubled Up 3-Unsheltered 4-Motel/Hotel Unaccompanied Youth 0-Not Unaccompanied 1-Unaccompanied-Received Srvs 2- Unaccompanied-No Srvs. Foster Care 1-Yes 2-No I certify the above named student qualifies for the Child Nutrition Program under the provisions of the McKinney-Vento Act. McKinney-Vento Liaison Signature Revised March 2015 SWPS Registration Application 13
11 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. Not 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) Student/Staff Identification Number (Parent/Guardian)/(Staff) Signature This space reserved for Local school observer upon completion and entering data in student software system, file this form in student s permanent folder. Ethnicity choose only one: Race choose one or more: American Indian or Alaska Native Hispanic / Latino Asian Black or African American Not Hispanic/Latino Native Hawaiian or Other Pacific Islander White Observer signature: Campus and : Texas Education Agency March 2010 (last update) Revised March 2015 SWPS Registration Application 14
12 Home Language Survey Student Name: School: Grade: Pre-Kindergarten TO BE COMPLETED BY PARENT OR LEGAL GUARDIAN: (1.) What language is spoken in your home most of the time? (2.) What language does your child speak most of the time? Parent/Guardian Signature What language do you prefer to recieve coorespondance from the school in? Quetionario De Idioma Hogarido Nombre del Estudiante: Escuela: Grado: DEBE DE COMPLETARSE POR EL PADRE OR GUARDIAN (1.) Cual es el idioma que mas se hable en su hogar? (2.) Cual es el idioma que mas habla su nino(a)? Firma Del Padre O Guardian Fecha Office use only: In the event the primary language is other than English notification to the ESL Coordinator is required by scanned copy of this document within 24 hours of enrollment. Staff Signature scanned Student enrolling in a Texas public school for the first time. Revised March 2015 SWPS Registration Application 15