CENTRAL JERSEY COLLEGE PREP

CENTRAL JERSEY COLLEGE PREP CHARTER SCHOOL Dear Parents/Guardians, Congratulations and welcome to the Central Jersey College Prep Charter School. We will do our best to help you with the enrollment process. Please fill out all of the enclosed forms and submit them to us in order to complete your child's enrollment. In this package you will find the following forms to fill out: 1. Enrollment form 2. Release of records (if your child was in a previous school) 3. Bus transportation form 4. Health forms 5. Elementary dismissal form (only for elementary students) Documents that are required to complete the registration process are; Transfer card (you will not be able to get this until the 2017-2018 school year has ended) Immunization records Birth certificate 2 proofs of residency (e.g. utility bills, driver s license) If you have any questions or concerns please do not hesitate to contact the school. 101Mettlers Rd, Somerset, NJ 08873 Ph: ( 732) 649 3954 Fax: ( 848) 216 3183 www.cjcollegeprep.org

Enrollment Form 2018-2019 DEAR PARENTS AND APPLICANT: Please fill out this form completely. Falsifications, misrepresentations or omissions may disqualify your application. Information you supply will not be given to any other person/company for any purpose. Please print clearly with blue or black ink. Student Information: Legal Name of Student: (last) (first) (middle) Preferred Name: Gender: Male Female Date of Birth: Home Phone: ( ) Ethnicity: (check one) American Indian/Alaskan Native Asian Black, not Hispanic Hispanic White, not Hispanic Native Hawaiian or other Pacific Islander Other Multiracial Grade level applying for: Kindergarten First Second Sixth Seventh Eighth Ninth Tenth Eleventh twelfth School Year: 2018/2019 Student s Residence Address: (Note: No P.O. Boxes) Street: Apt #: City: County: State: Student s Mailing Address: ( Check here if same as residence address.) Zip Code: Street: Apt #: City: County: State: Zip Code: Legal School District of Residence: Is student s current school located in this district? Yes No If No, fill in district name: Previous School Information: Name of Current School: Type of School: Public School Private School Registered Home School Charter School Not in school/other Address of Current School: Street: City: State: Zip Code: School Phone: _( ) School Fax: _( ) Name of Previous School: Type of School: Public School Private School Registered Home School Charter School Not in school/other Is applicant currently under expulsion from any school or district? No Yes If yes, explain: Has the applicant ever skipped a grade? No Yes which grade and why? Has the applicant ever repeated a grade? No Yes which grade and why? Page 1 of 6

Parent/Guardian Information: Student lives with: Both parent Both parent alternately (Joint custody) Mother only Father only Legal guardian Father s Name: Address and phone same as student? Yes No If No, complete the following: Street: Apt #: City: County: State: Zip Code: Name of Employer: Occupation: Work Address: Street: Suite #: City: County: State: Zip Code: Work Phone: ( ) Home Phone:( ) Cell Phone: ( ) E-mail address: Mother s Name: Address and phone same as student? Yes No If No, complete the following: Street: Apt #: City: County: State: Zip Code: Name of Employer: Occupation: Work Address: Street: Suite #: City: County: State: Zip Code: Work Phone: ( ) Home Phone:( ) Cell Phone: ( ) E-mail address: Stepparent/Legal Guardian s Name: Address and phone same as student? Yes No If No, complete the following: Street: Apt #: City: County: State: Zip Code: Name of Employer: Occupation: Work Address: Street: Suite #: City: County: State: Zip Code: Work Phone: ( ) Home Phone:( ) Cell Phone: ( ) E-mail address: Emergency Contacts: If a parent cannot be contacted we will attempt to contact one of the following in the order listed below. Please list at least one emergency contact. FIRST person to contact if parents cannot be reached: Name: (last) (first) Relationship: Home Phone: ( ) Cell Phone:( ) Work Phone: ( ) SECOND person to contact if parents cannot be reached: Page 2 of 6

Name: (last) (first) Relationship: Home Phone: ( ) Cell Phone:( ) Work Phone: ( ) Sibling Information: Siblings Birth Date Attending School Relationship to Student 1 2 3 4 5 6 7 Special Programs Has your child been evaluated for and/or participated in any of the following special services? Gifted & Talented Title 1/Chapter 1 Program Special Education (IEP) English as a Second Language (ESL) Other: If you checked Special Education (IEP), do you have the student s special education records? Yes No Photo/Video Release During the course of your child s enrollment at CJCP, there are occasions where the Central Jersey College Prep take pictures/videos of your child participating in events/activities. We use these pictures/videos in CJCP publications, local newspapers, school website, homerooms, advertising, or on a display at the Central Jersey College Prep. We kindly ask that you sign a photo/video release for your child. Thank you in advance for your support and understanding. I give my consent for CJCP to use pictures/video of my child. I do not give my consent for CJCP to use pictures/video of my child. Page 3 of 6

Health Insurance and Health Information Primary Physician Information: Doctor Name: Doctor Phone: Dentist Name: Dentist Phone: Type of Health Insurance: HMO Medicaid No health insurance Other Insurance Provider: If the student is covered by Medicaid, provide the Medicaid number: Read and check: I understand that for those school health and health-related services that the Medicaid-eligible student may be receiving including but not limited to: vision and hearing screenings, nursing services, speech therapy, occupational and/or physical therapy the school district has the right to receive partial reimbursement from Medicaid for those services rendered. Please list any serious allergies, conditions, or restrictions the student has: Please list any physical or emotional disabilities the student has: Please indicate any special health or other needs of which we should be aware and which will help us plan and provide for the applicant s educational experience: EMERGENCY RELEASE CJCP will attempt to reach the parent/legal guardian or one of the people listed as an emergency contact but if none of these people can be reached, CJCP personnel have my permission to use discretion in securing medical aid in an emergency. IT IS UNDERSTOOD THAT NEITHER THE CJCP NOR THE PERSON RESPONSIBLE FOR OBTAINING THIS MEDICAL AID WILL BE RESPONSIBLE FOR THE EXPENSE INCURRED. Parent/Guardian Signature: Date: Page 4 of 6

HOME LANGUAGE QUESTIONNAIRE (HLQ) In order to provide your child with the best possible education, we need to determine how well he or she understands, speaks, reads, and writes English. Your assistance is answering these questions is greatly appreciated. What language(s) is spoken in the student s home or residence? English Other: What language(s) is spoken most of the time to the student, in the home or residence? English Other: What language(s) does the student understand? English Other: What language(s) does the student speak? English Other: What language(s) does the student read? English Other: Does not Read What language does the student write? English Other: Does not Write In your opinion, how well does the students understand, speak, read and write English? Very well Only a little Not at all Understands English Speaks English Reads English Writes English Page 5 of 6

Enrollment Acceptance Statement of Educational Equality: The Central Jersey College Prep is committed to a policy of educational equality. Accordingly, the program admits students and conducts all educational programs, activities, and employment practices without regard to race, color, religion, gender, sexual preference, national origin, marital status, ancestry, disability, or any other legally protected classification. Any person having inquiries concerning the school s compliance with regulations implementing Title VI of the Civil Rights Act of 1964, Title IX of the Educational Amendment of 1972, Section 504 of the Rehabilitation Act, the American with Disabilities Act, or the Individuals with Disabilities Education Act is directed to contact the School Director at the school address. Please accept this signed and completed document to enroll to the Central Jersey College Prep for the 2018-2019 academic year. (Student s name) I/We, the undersigned, hereby certify that, to the best of my/ our knowledge and belief, the answers to the foregoing questions and statements made by me/us in this application are complete and accurate. I/we understand that any false information, omissions, or misrepresentations of facts may result in rejection of this application or future dismissal of the applicant. Parent/Guardian s Signature: Date: Page 6 of 6

NEW JERSEY STATE DEPARTMENT OF EDUCATION (B6T) APPLICATION FOR PRIVATE SCHOOL TRANSPORTATION OFFICE OF STUDENT TRANSPORTATION Please submit a separate application for each child to the private school SCHOOL YEAR 2018-2019 RESIDENT DISTRICT BOARD OF EDUCATION STUDENTS NAME DATE OF BIRTH LAST FIRST MIDDLE MONTH DAY YEAR GENDER PARENT/GUARDIAN NAME DAYTIME PHONE MorF AREA CODE + NUMBER HOME ADDRESS CITYorTWP ZIP NEAREST INTERSECTION TO STUDENTS RESIDENCE MAILING ADDRESS ZIP FULL NAME OF SCHOOL TO BE ATTENDED Central Jersey College Prep Charter School phone 732-302-9991 ADDRESS OF SCHOOL 101 Mettlers Road, Somerset, NJ 08873 SHORTEST ONE-WAY MILEAGE STUDENTS GRADE FOR THE COMING YEAR BETWEEN HOME AND SCHOOL walkways in miles and tenths) MILES TENTHS DATE SCHOOL OPENS CLOSES SCHOOL HOURS FROM AM TO PM NAME AND ADDRESS OF SCHOOL OF ATTENDANCE IN PRIOR YEAR DATE SIGNATURE DO NOT WRITE BELOW THIS LINE * FOR PUBLIC SCHOOL USE ONLY YOUR APPLICATION HAS BEEN REVIEWED BY THE RESIDENT DISTRICT BOARD OF EDUCATION, THE FOLLOWING DETERMINATION HAS BEEN MADE: TRANSPORTATION WILL BE PROVIDED YOU ARE ELIGIBLE FOR PAYMENT IN LIEU OF TRANSPORTATION INELIGIBLE (REASON) DATE SIGNATURE TITLE INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR PRIVATE SCHOOL TRANSPORTATION (B6T) N.J.A.C. 6Ar27-2.5 1. IT IS THE OBLIGATION OF THE PARENT OR GUARDIAN OF PRIVATE SCHOOL STUDENTS TO: ANNUALLY OBTAIN THE APPLICATION FOR PRIVATE SCHOOL TRANSPORTATION FROM THE ADMINISTRATIVE OFFICE OF THE PRIVATE SCHOOL FOR EACH STUDENT FOR WHICH TRANSPORTATION SERVICES ARE BEING REQUESTED. SUBMIT A SEPARA TE APPLICATION FOR EACH STUDENT. NOTE: o IF THERE IS A CHANGE OF HOME ADDRESS, A NEW APPLICATION SHALL BE SUBMITTED TO THE PUBLIC SCHOOL DISTRICT OF RESIDENCE. o IF THERE IS A CHANGE IN THE NONPUBLIC SCHOOL OF ATTENDANCE, A NEW APPLICATION SHALL BE SUBMITTED TO THE PUBLIC SCHOOL DISTRICT OF RESIDENCE. COMPLETE THIS APPLICATION AND RETURN IT TO THE PRIVATE SCHOOL ON OR BEFORE MARCH 10 PRECEDING THE SCHOOL YEAR IN WHICH TRANSPORTATION IS BEING REQUESTED. LATE APPLICATIONS - ANY APPLICATION RECEIVED AFTER MARCH 10 WILL BE A LATE APPLICATION AND MUST BE ACCOMPANIED BY A STATEMENT OF THE REASON FOR LATENESS. ELIGIBLE STUDENTS WILL RECEIVE TRANSPORTATION OR AID IN LIEU OF TRANSPORTATION BASED ON THE DATE THE APPLICATION IS RECEIVED BY THE PUBLIC SCHOOL. 2. IT IS THE OBLIGATION OF THE NONPUBLIC SCHOOL ADMINISTRATOR TO ANNUALLY COLLECT THE APPLICATION AND SUBMIT IT TO THE PUBLIC SCHOOL FROM WHICH TRANSPORTATION IS BEING REQUESTED PRIOR TO MARCH 15. 3. IT IS THE OBLIGATION OF THE PUBLIC SCHOOL ADMINISTRATOR TO NOTIFY THE PARENT OR GUARDIAN AS TO THE DETERMINATION OF EACH APPLICATION BY AUGUST 1^^. A DISTRICT BOARD OF EDUCATION SHALL PAY AID IN LIEU OF TRANSPORTATION TO THE PARENT OR GUARDIAN OF AN ELIGIBLE STUDENT ONLY AFTER RECEIVING A SIGNED "REQUEST FOR PAYMENT OF TRANSPORTATION AID" VOUCHER AS PRESCRIBED BY THE COMMISSIONER OF EDUCATION. C;\Users\Dina Agiular\Desktop\2018-2019 Transportation\B6T 2018-2019 Version 3/2014

CENTRAL JERSEY COLLEGE PREP C H A R T E R S C H O O L Dear Parents/ Guardians, Welcome to the 2018-2019 School Year! We ask that you please inform the health office of all health conditions whether or not they require treatment or medication during the school day. This includes but is not limited to asthma, severe allergy with potential for anaphylaxis, seizures, diabetes, and blood disorders. These conditions require an emergency action plan completed by the physician and the parent, to be renewed each academic year. All health forms are located at the school website under the Parent- Nurse- Forms tabs. Emergency Action Plans Please complete only the health forms which applies to your child. The forms must be signed by the parent and physician and return to the school nurse with medication(s) in the original pharmacy labelled container(s). Students with diabetes must provide a management plan signed by their physician. If insulin is a part of the management plan, complete both forms for insulin and glucagon. For students with asthma, an action plan completed by a physician should indicate if the student can self-administer treatment. Students at risk for anaphylactic reaction ex. food allergies, must complete an allergy action plan, medication form and provide EpiPen to the Nurses` office. The doctor must indicate what table your child should sit on (allergen free table). Students who need to take over the counter medication at school, must also have their doctor complete the medication form. If your child must self-administer and/or self carry emergency medications including EpiPens, and inhalers, both you and the physician need to sign off on the emergency action plan. If your child is certified to self-carry medications, they may self-carry emergency medications only. For students not certified to self-carry, emergency medication will be left in the nursing office. I will be available to meet after school in September to discuss your child's specific emergency action plan and any health concerns you may have for your child. Please contact me at the beginning of the school year by phone at 732-649-3954 ext.1216 or by email at wbukong@cicollegeprep.org to arrange a mutually convenient time. If your child was on a 504 plan in a previous year and/or in a previous school due to their health status, inform the nursing office, and we will arrange a meeting with you to reevaluate your child's 504 Plan. Medication Policy Over-the-counter medication must be supplied by you to the nurse's office in a labeled original

CENTRAL JERSEY COLLEGE PREP C H A R T E R S C H O O L container with the child's name written on it. This includes but is not limited to Tylenol, Advil, Cough Syrup, Midol, etc. Prescription medication must be clearly labeled by the pharmacy. An order must be provided including name, dose, length of time prescribed, dose intervals, potential side effects and interactions, and expected outcome from the healthcare provider. All medication forms must be signed and filled out completely by the child's healthcare provider, including OTC medications, in order to be administered. If you are unable to obtain a signed form, you may bring the medication to school and administer it to your child yourself in the nurse's office. If your child requires medication during an overnight school trip that would not normally be given during the school day, please inform us ahead of time so that special arrangements can be made. Immunization and Health Physicals We require a copy of your child`s health physical examination and immunization records seven days before the first day of school. If your child`s immunization record is not up-to-date, he/she will be excluded until it is updated. For children without health insurance, please visit www.state.nj.us/health. Sports Students who intend to participate in competitive sports during the academic year, should visit the athletic department tab on the school website. All forms are due two weeks prior to trials. Emergency Contact Information This form is located on genesis (under student data-forms tabs), it should be complete before the first day of the school year and updated as needed during the school year. Sincerely, Wawa A. Bukong, CSN, BSN, RN School Nurse 732-649-3954 ext. 1216

NEW STUDENT HEALTH AND PHYSICAL EXAM FORM HEALTH HISTORY (to be filled out by PARENT/GUARDIAN) Student s Name: Birth Date: Sex M F Grade: Languages Spoken at home: Parent / Guardian Name: HEALTH HISTORY Does the student have or have had any of the following medical conditions: DISEASE HISTORY Yes NO DISEASE HISTORY Yes No Asthma Diabetes Seasonal Allergies ADHD/ ADD Chronic Otitis Media Lyme Disease Hepatitis Rheumatic Fever Strep Infections Chicken Pox Mononucleosis Influenza (Flu) Heart Disease Fractures Autism Spectrum Disorders Concussions Neuromuscular Disease Convulsive Disorder Auto Immune Disorders Juvenile Rheumatoid Arthritis Congenital Disorders Hematologic Disorders Vision Disorder Hearing Disorder Please provide further details on any yes answers: Operations or Serious Hospitalizations: Current Medications (Name, Dose, Frequency and Reason used): Allergies: (Name, reaction to exposure) Drug: Food: Environmental: Any Other Additional comments or information that you would like to provide:

Student s Name: Exam Date: PHYSICAL EXAM Height: Weight: Pulse: B/P: Vision: Uncorrected Right: Left: Vision: Corrected Right: Left: Hearing Screen: Right: Left: Head Eyes Ears Nose Throat Lymph Glands Heart Lungs Abdomen Hernia Genitalia Skin Orthopedic Scoliosis Neurological Speech Nutrition Normal Exam Abnormal Findings: Physical Exam Comments: Any Limitation of Activity or other Recommendations? No Yes (Please define): 1. If the student will be required to have medications at school such as an Epi-Pen, Asthma inhalers, and other medications for chronic Please fill out the appropriate medication packets. 2. Please attach a copy of the student s immunization records, and include any recent TB screening results. Physician Signature: Date: Name and Address Stamp:

AUTHORIZATION FOR ADMINISTRATION OF OVER THE COUNTER MEDICATION IN SCHOOL FOR ACUTE ILLNESSES Our School Medical Inspector, Sathesh Porur Evalappan M.D., has authorized the administration of the following medications by the School Nurse in the School Health Office. However, parental/guardian permission is required before a student can receive any of the listed medication. If you would like your child to be able to receive any of the listed medication in school if needed, please complete the following and return it to the Health Office. Students will receive only ONE DOSE during the school day. Telephone verbal permission from a parent/guardian will be requested prior to the administration of medication. The following section is to be completed by the PARENT/GUARDIAN: Student s Name Grade I request that my child be assisted in taking the medication described below at school by the School Nurse or other individuals authorized to administer medication to students in school pursuant to N.J.A.C:.6A:16-2.3. I understand the ultimate responsibility for administration of the medication is mine, and I am fully aware that the duties of the school nurse and others may require their presence at another location at the time that the medication is needed. I understand that the school district, agents and its employees shall incur no liability as a result of any condition or injury arising from the administration or lack of administration of the medication prescribed on this form. I indemnify and hold harmless the School District, its agents and employees against any claims arising out of administration or lack of administration of this medication. I authorize the administration of (Check all that apply) Acetaminophen dosed according to weight and product label. Ibuprofen dosed according to weight and product label. TUMS dosed according to product label. Signature (parent/guardian): Date: Name: Work Phone: Home Phone: Cell: RECOMMENDATIONS ARE EFFECTIVE FOR ONE (1) SCHOOL YEAR ONLY AND MUST BE RENEWED ANNUALLY

CENTRAL JERSEY COLLEGE PREP CHARTER SCHOOL Elementary Dismissal Form Central Jersey College Prep is requesting your child s intended dismissal routine for the 2018-2019 school year. Please choose your child s permanent dismissal routine for the upcoming school year by circling below and returning this form with your enrollment packet. Thanks in advance! Child s Name: Grade entering: 2018-2019 Dismissal ( circle one ): 1. Bus 2. Parent Pick - Up Parent/Guardian Name: Parent/Guardian Signature: 101 Mettlers Rd, Somerset, NJ 08873 Ph: ( 732) 649 3954 Fax: ( 848) 216 3183 www.cjcollegeprep.org

CENTRAL JERSEY COLLEGE PREP CHARTER SCHOOL Release of Records To: (Name of Previous School) Address: Street: City: State: School Phone: ( ) School Fax : ( ) Central Jersey College Prep has enrolled for the 2018-2019 academic year. Please accept this document as formal approval for the release of all official school records, including: Official transcripts(or report card) Testing information Attendance and discipline records Special Education Information (IEP)******** Original transfer card Original health and immunization records Guidance records/information Parent/Guardian Signature: Date: Please forward all records to: Central Jersey College Prep Charter School 101 Mettlers Rd. Somerset, NJ 08873 ATTN: Student Records 101Mettlers Rd, Somerset, NJ 08873 Ph:( 732) 649 3954 Fax: ( 848) 216 3183 www.cjcollegeprep.org