dear parent or guardian, - ucpcfl.org · dear parent or guardian, thank you for considering ucp of...
TRANSCRIPT
Dear Parent or Guardian,
Thank you for considering UCP of Central Florida’s Education Program. We believe every child deserves excellent academics to help them learn, grow and excel. That’s why each of our classrooms is led by highly-qualified and experienced teachers who welcome children and families into a community of learning. Our research-based academics lay the foundation for each student’s future success.
The mission of UCP Charter Schools is to create a fully inclusive learning community where all students, parents, and professionals appreciate and value diversity in all forms. Students are educated to become conscientious responsible citizens, whereby they assume the role of life-long learners as they reflect upon and contribute to the cultural and civic life of their community. All students are supported to achieve high standards in both their academic and personal development through a research-based educational program utilizing an inquiry/project-based program integrating arts and technology.
Please find enclosed UCP’s application for enrollment. The next step in the enrollment process is the completion of this packet and submission of other documents. It is important that you complete each form in the packet as much as possible. Additionally, please use the Checklist to gather the other needed documents. Please return this packet and the materials to the front desk at the campus in which you are applying.
Once all materials are received, your child will be evaluated for placement and you will be notified of the next steps. If you have any questions on the process or forms/documents, please contact the Family Service Case Manager at your child’s campus at 407-852-3300:
UCP Seminole – x2000 UCP TLA – x8323 UCP West Orange – x5000
UCP Bailes/East Orange – x1000 UCP Downtown/ BETA – x7313 UCP Osceola – x6000 UCP Pine Hills – x4000
Thank you again for considering UCP of Central Florida!
Dr. Ilene Wilkins, President/CEO
Thank you for selecting UCP of Central Florida as your child’s school provider. Please fill out each page of the packet as thoroughly as possible. In addition, please look over the enclosed list of items and bring the applicable documents with
you to your child’s school before the first day of class.
Verification of legal name and age with child’s birth certificate.
Proof of immunizations on Florida State Form 680, which can be obtained from your physician or at the HealthDepartment in the following counties (please call the Health Departments for details and requirements):
• Orange County Health Department (407-836-2502) at 832 W. Central Blvd., Orlando• Seminole County Health Department in Sanford (407-665-3281) or Casselberry (407-665-3409)
• Osceola County Health Department in Boggy Creek (407-343-2066), Poinciana (407-943-8600) orSt.Cloud (407-943-8699)
**Proof of physical examination on Florida Department of Health Form 3040, performed by a U.S. doctor within 1 yearof school enrollment (1st day of school). If documentation cannot be provided, a physical examination must be scheduledwithin 30 days of the first day of school.Note: Seminole County Public Schools’ policy does not grant a 30 day extension to obtain required immunizations or aphysical.
Verification of Academic History
1. Last report card -- if applicable.
2. Withdrawal form from previous school (private, public, in-state, or out of state) if applicable. Forstudents with a disability please bring an Individual Education Plan (IEP) and most recent psychoeducation evaluation.
3. School transcript
Verification of Special Education1. Children age 0-3 with disability - Part C / Early Steps / Individual Family Support Plan (IFSP)
2. Children over 3 years of age with a disability - School District Individual Education Plan (IEP) andmost recent psycho education evaluation.
Verification of your residential address in the appropriate county with one of the following*:1. Current Homestead Exemption Card or Purchase Contract or Warranty Deed2. Lease / Rental Agreement3. Verification of address: Documents required-information available on County School District website.
(Seminole County has different requirements)
Guardianships - If you are not the legal guardian or residential custodial parent of a student, state law requiresthat one of the following documents be provided for enrollment
1. Court Custody Documentation – this includes divorce decrees, parenting agreements (if applicable)2. Department of Children and Families Placement Letter3. School Educational Guardianship notarized statement from public school system
Copy of VPK documentation/VPK Voucher (if applicable)
Medical Records & Evaluations (for therapy services only)1. Insurance Card, Policy Card or Medicaid Card2. Physicians Script for Evaluation (with diagnosis)3. Copies of all previous therapy evaluations, progress notes and discharge reports4. Copies of all relevant previous medical records within the last two years
*Temporary Documentation Exemption: Students who lack a fixed, regular and adequate nighttime residence, have a right to immediate enrollment underthe McKinney-Vento Homeless Assistance Act 42 U.S.C. 11435. A completed Student Residency Questionnaire is needed to determine eligibility.
**Seminole County Public School’s policy does not grant a 30-day extension to obtain required immunizations or a physical. Immunization and physicals may be obtained through your physician.
Bailes/East Orlando Campus (Near UCF)
Downtown/BETA Campus
Osceola/Kissimmee Campus
Pine Hills Campus
**TLA Campus (South Orange Ave.) Seminole/Lake Mary Campus
West Orange/Winter Garden Campus
Visit:
www.ucpcfl.org for more information.
** Middle and High School & College/Career Transition Program ** Campus serves grade 6 through age 21.
Student Number_________________________ [OFFICE USE ONLY]
*Child’s Legal Name:
First MI Last Generation (i.e.: Jr., II)
Date of Birth Birth Place (City, State, Country)
Social Security Number (Optional) Grade at Entry
*Residential Address:
Street Address
City State Zip County
*Mailing Address: Check if same as residential
Street Address
City State Zip County
*Ethnicity: Hispanic/Latino Non Hispanic/Non Latino
*Race (Check all applicable): White Asian Black or African American
American Indian/Alaska Native Native Hawaiian or other Pacific Islanders
*OK to Release Directory Information? Yes No
(Answering “yes” to one or more of the home language questions below, will require your child to be screened for English Language proficiency)
*Home Language: Is a language other than English spoken at home?
Yes No If yes, what language?
*Dominant Language: Does the student most frequently speak a language other than English?
Yes No If yes, what language?
*Native Language: Did the student have a first language other than English?
Yes No If yes, what language?
Do you need communication sent home in a language other than English?
Yes No If yes, check all that apply: Spanish French Portuguese
Haitian Creole Vietnamese Other________
Born Outside the United States?
Yes No *If yes, Date entered in U.S.?
*Date your student entered first U.S. school:
Child resides at residential address with:
/ / (Mo/Day/Year)
Both parents Mother only Father only Parent and step parent
Legal guardian Foster Parent Other:
Form
* denotes required field - please fill out.
*Verification of Residence required for Parent or Guardian without a lease or living with another person
*Gender: M F
Residential Information (Please check all that apply): Parent/Guardian is in Federal Military Services or is a civilian employee
Parent/Guardian has lived in Florida for the past year or longerParent/Guardian has purchased and occupies as his/her domicile a home in Florida
Y
Parent/Guardian is a migratory agriculture worker
Parent/Guardian has a *Verification of Residence:
Parent/Guardian has a valid lease agreement: Y N N
Expiration Date:___________________
Other School Age Children Living at Home:
Child’s Name (First and Last) Relation to Students School Grade
1.
2.
3.
Has your child been identified as an exceptional education student? N Y
Does your child have a current IEP, 504 or IFSP? N
Has your child ever received a McKay Scholarship?
Y Please Bring a Copy
N
IEP 504 IFSP
Y
*School History (Begin with the most recent - For Kindergarten registration, please list Pre-K)
Please check here if your child has ever attended any Florida School.
When______________ City______________ County______________ Public Private
1. Current School:
School Name Address Phone Number
Type of School Years Attended Last Grade Completed
Public Home Education Private
2. Past:
School Name Address Phone Number
Type of School Years Attended Last Grade Completed
Public Home Education Private
3. Past:
School Name Address Phone Number
Type of School Years Attended Last Grade Completed
Public Home Education Private
Program Participation Prior to Kindergarten: (Check all that apply)
(V) Voluntary Pre-Kindergarten at a Public School School Name:
(P) Pre-Kindergarten Program (VPK) at Private School School Name:
(D) Pre-Kindergarten Program for children with Disabilities School Name:
(H) Head Start School Name:
(F) School District Pre-K School Name:
(M) Migrant Pre-K School Name:
(C) Title 1 Pre-K School Name:
(T) Teenage Parent Program Pre-K School Name:
(N) None
* denotes required field - please fill out.
Has student been arrested, resulting in a charge? N Y
(If yes to previous) Date: Name of school: County/State:
Has student been expelled from a previous school? N Y
Name of school: (If YES) Date:
First MI Last
Street Address City State Zip
Home Phone Cell Phone E-mail Address
Date of Birth Relationship to student Legal Documentation (Ex: custody, restraining order, etc.) If there is no Legal Alert: Enter “N/A” *Please provide supporting documentation
837.06 False official statements. - Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his or her official duty shall be guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 775.083
Falsification of information will forfeit student’s athletic and extracurricular activity for one (1) calendar year from the date of discovery of the violation.
Best time to call: Evening
Marital Status: Widowed
Employment Status:
Divorced
Part Time
Separated
Retired Self-Employed
Parent Family Income:
Afternoon
Married
Full Time
Not Working
$10,000-$14,999 $15,000-$19,999 $20,000-$29,999
Morning
Single
Active Military
In School/Training
Below $10,000
$30,000-$49,999 $50,000-$74,999$ 75,000-$99,999 $100,000 and above
Has student ever had Juvenile Justice action taken against him/her? N Y
NIs student on Community Control? Y
Is the student a parent? N Y
NCurrently under Physician’s Care? Y
Physician Information:
Primary Doctor’s Name Address Phone
Primary Dentist’s Name Address Phone
Preferred Hospital: ___________________________________________________________________
Funding Information (Check all that apply)
Kid Care 4C Early Steps Early Head Start Commercial InsuranceMedicaid HMO
Private Pay
Medicaid
Other:
Insurance Information If Commercial Insurance, please complete the following.
Policy Holder’s Name Name of Insurance
Group # Policy #
*Parent/Guardian #1 Information:
Custody:
Y N
OK to pick up:
Y N
Parent Guardian Guardian Ad Litem Surrogate Parent Other/Relative
Address:
Parent/Guardian is a:
Primary Parent’s Employer:
Phone: Occupation:
Parent/Guardian #2 Information:
Custody: (Circle One)
Y N
OK to pick up: (Circle One)
Y N
First MI Last
Street Address City State Zip
Home Phone Cell Phone E-mail Address
Date of Birth Relationship to student Legal Documentation (Ex: custody, restraining order, etc.)
837.06 False official statements. - Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his or her official duty shall be guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 775.083
Falsification of information will forfeit student’s athletic and extracurricular activity for one (1) calendar year from the date of discovery of the violation.
Military Family Student Survey:
No Yes
No Yes
No Yes
Parent is an active duty member of the uniformed services, including members of the National Guard and Reserve on active-duty orders.
Parent is a member or veteran of the uniformed services who is severely injured and medically discharged or retired for a period of 1 year after medical discharge or retirement.
Parent died as an active duty member of the uniformed service or within one year of injury.
Evening
Divorced
Part Time
Separated
Retired
Widowed
Self-Employed
Best time to call:
Marital Status:
Employment Status:
Parent Family Income:
Afternoon
Married
Full Time
Not Working
$10,000-$14,999 $15,000-$19,999 $20,000-$29,999
Morning
Single
Active Military
In School/Training
Below $10,000
$30,000-$49,999 $50,000-$74,999$ 75,000-$99,999 $100,000 and above
Parent Guardian Guardian Ad Litem Surrogate Parent Other/Relative
Address:
Parent/Guardian is a:
Primary Parent’s Employer:
Phone: Occupation:
How did you hear about UCP of Central Florida? Physician
Name:
UCP Staff Member
Name:
Address: Former Student
Name:Hospital:Early StepsSocial Media/Google
MailingEarly Head StartSchool: Orange County Public SchoolsSchool: Seminole County Public SchoolsSchool: Osceola Public School System
School: Other:4CParent
Name:
WebsiteInternet SearchFacebook
TwitterYouTubeAdvertisement: MagazineAdvertisement: PostcardAdvertisement: Flyer
Advertisement: NewspaperOther :
As the custodial (custody at least 50% of the time) / enrolling parent I verify that the information provided above is true and correct, and understand that The School District of Orange, Osceola and Seminole Counties will rely upon this information as true and correct. Parent acknowledges that there are legal penalties, including possible criminal penalties, for intentionally providing false information to the School District. I further understand that providing false or misleading information may result in my child being excluded from school.
Parent/Guardian Signature #1 :
Date: ______________ Relationship to student: _________________
Parent/Guardian Signature #2:
Date: ______________ Relationship to student: _________________
I, hereby authorize UCP of Central Florida to request information on this child as indicated below.
Name of Child: Child’s Date of Birth:
Agency:
(Check all that apply)
4C/Early Head Start
Child Find (FDLRS)
Children’s Medical Services
County School District:
County Health Dept.:
Department of Children and Families
Division of Blind Services
Easter Seals
Early Steps/Part C
Pediatrician:
SSI
United Cerebral Palsy of
Other:
Types of information that may be shared:
(Check all that apply)
Psychological Testing
Social/Developmental History
Speech/Language and Hearing Reports
Vision/Hearing/Screening Results
Occupational/Physical Therapy Records
Developmental Assessment Reports
IFSP or IEP
Medical Information and Reports Including:
Medical Records
Immunizations
Physical Examinations Reports
Laboratory Reports
HIV Test Results
Other List:
Other:
I am aware that the information shared will be strictly confidential and cannot be released to anyone else without my written consent. I am aware that I may deny consent to any of the agencies listed above and that I may withdraw my consent at any time by notifying UCP of Central Florida in writing.
Signature of Parent or Legal Guardian Date
Witness Date
The execution of this form does not authorize the release of information other than that specifically described above.
The information requested on this form is solicited under Title 38, U.S.C. The form authorizes release of information in
accordance with the Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164, 5 U.S.C. 552a,
and 38 U.S.C. 5701 and 7332 that you specify.
for of 1
Date: Student Number:
To Whom It May Concern:
The following student has enrolled at our school. Please send all records including grades, courses taken, test scores, special education, psychological data, current individualized education plan (IEP), health records and immunization dates. Also, please include all grades earned this school year and/or withdrawal grades, if any.
Identifying Information
Student’s Name:
First
Date of Birth:
Middle Last
Parent(s)/Guardian(s) Name: Phone #:
Name of Last School Attended:
Complete Mailing Address of Last School Attended:
Street City State Zip
Phone # Fax #
Send Requested Records To:
Parent/Guardian Signature Date
For Principal or Records Clerk Only
Prior written consent of the parent or guardian of the student is not required to transfer records to schools in
which the pupil or student seeks or intends to enroll.
1st request
2nd request
3rd request
for of 2
Medical History
Child Name:
Pregnancy / Delivery
Pregnancy Proceeded Without Complications
With Complications
Eclampsia
Gestational Diabetes
Multiple Births
Polyhydramnios
Positive for Cytomegalovirus 'CMV'
Positive for Herpes
Positive for HIV
Positive for Strep B
Pre-eclampsia
Premature Labor
Substance Exposure
Toxemia
Other
Length of Pregnancy (in weeks) Prenatal care was Received Not Received
Delivery Proceeded Without Complications
With Complications
Abruptio Placenta
Breech Presentation
Low Birth Weight
Negative Vacuum
Non-progressive/unproductive Labor
Occiput Posterior Position (Face up)
Placenta Previa
Premature Rupture of Membranes
Transverse Presentation
Prolapsed Cord
Use of Forceps
Uterine Rupture
Umbilical Cord Wrapped Around Neck
Other
Delivery was Vaginal C-section Emergency C-section Length of child's hospital stay:
Mother's age at time of birth Birth Hospital
Needed to be transferred to another hospital Yes No
Transfer Hospital
Birth Weight Birth Height Apgar 1 min 5 min 10 min
Additional Comments
Multiple child pregnancies: # of live births: # of still births:
Additional details of birth
Complications Following Birth
Anemia of Prematurity
Bronchopulmonary Dysplasia 'BPD'
Cleft Lip
Cleft Palate Club
Foot
Cytomegalovirus
ECMO
Failure to Thrive
Hyperbilirubinemia
Intrauterine Growth Retardation 'IUGR'
IVH Bleed Grade I
IVH Bleed Grade II
IVH Bleed Grade III
IVH Bleed Grade IV
Jaundice treated by light therapy &/or blanket
Meconium Aspiration
Necrotizing Enterocolitis 'NEC'
Neonatal hypoxia
Oxygen dependency
PDA
Positive dependency
Respiratory Distress Syndrome
Respiratory Stridor
Respiratory Syncytial Virus 'RSV'
Retinopathy of Prematurity 'ROP'
Thrombocytopenia (Low Platelet count)
Ventilator Dependency
VP Shunt
Other
Diagnosed or Suspected Syndromes
Current Medications
Allergies
Current Vitamins, Herbs, Minerals, Homeopathics
Current Physicians
Diagnostic Tests
Hearing Test
Never Tested, No Concerns
Never Tested, Have Concerns
Normal Test Results
Abnormal Test Results
Last Test Date
Vision Test
Never Tested, No Concerns
Never Tested, Have Concerns
Normal Test Results
Abnormal Test Results
Last Test Date
Results
Concerns
Results
Concerns
Current Physicians
Name Specialty Reason Date of last visit
Diagnostic Tests
Test When Details/Results
Auditory Brainstem Response Biopsy Blood Work / Lab Tests Bone Density Scan CT Scan EEG EMG Lower GI Motility Study / Empty Scan MRI NCV Swallow Study Ultrasound Upper Endoscopy X-Ray
Surgeries and Procedures
Surgeries and Procedures
Type Date Results/Details
Does the child have: Allergies
Arteriovenous malformation (AVM)
Anoxic brain injury
Asthma/respiratory breathing problems
Autism
Baclofen Pump
Cerebral Palsy (CP)
Cerebral Vascular Accident (CVA)
Chronic Ear Infections
Other Medical Conditions
Orthopedic Conditions
Colic
Constipation
Diarrhea
Down Syndrome
Hip subluxation
Hydrocele
Laryngomalacia
Muscular Dystrophy
Osteoporosis
Periventricular Lukomalasia
Reflux
Scoliosis Degrees?
Seizure Condition
Sleep disorder
Sleep problems
Shunts
Torticollis
Traumatic brain injury (TBI)
Tube Feeding
Tubes in ears
Vagal Nerve Stimulator
None
Additional Comments
Is the child able to: Began at age (in months):
Developmental History
Is the child able to: Began at age (in months):
Bringing both hands to mouth
Buttoning pants/shirt
Come to sitting from a lying position
Creeping or crawling alone
Fully Toilet trained
Grabbing a toy
Holding head up alone
Pulling self to standing position
Rolling Over
Self-bathing
Self dressing
Sitting alone without support
Standing unsupported
Tying shoes
Walking with support
Walking unaided
Zipping/unzipping jacket
Is your child Right Handed Left Handed Neither
Concerns about handwriting? Yes No Describe:
How does child get around the house?
Favorite Toys / Play Activities
Description of Child
Active
Affectionate
Aggressive
Calm
Cautious
Curious
Demanding
Difficult to Comfort
Distractible
Fearful
Fearless
Fussy
Insecure
Motivated
Passive
Persistent
Playful
Shy
Stubborn
Withdrawn
Other:
Sensory processing & Regulation (please select all that apply)
Avoids getting messy
Seeks out (craves) touch or movement
Stumbles or falls frequently
Appears awkward or less coordinated
Flaps hands
Allows brushing of teeth
Bangs on surface, bangs/hits head
Fatigues quickly
Has self-abusive behaviors
Resists certain tasks or environment
Spins things or self
Is sensitive to lights,sounds or noise
Sleeps a lot
Resists touch
Walks on toes
Lines up toys or objects
Seeks out (craves) visually stimulating objects
Seeks out (craves) stimulating sounds
Resists certain movements (e.g. bouncing,
swinging, upside down)
Has difficulty figuring out how to move body or takes more time with movements
Does not tolerate certain textures (e.g. clothing,surfaces,foods)
Uses lots of pressure when touching someone or holding object
Has difficulty transitioning from one activity to another
Has difficulty falling asleep
Has difficulty remaining asleep through the night
Appears Lethargic/sleepy all the time
Has poor sense of body in space, runs into things
Seeks support for posture (e.g. leans on furniture, walls or
people, holds head)
Demonstrates stiff or rigid movement patterns
Hyperfocussed (on specific tasks, people, objects, etc.)
Other: please describe
Feeding Milestones
Communication Skills
Speech Milestones
Social/Emotional Skills
Is easily distracted
Calms self easily
Gets angry/frustrated easily
Is aggressive towards others
Prone to emotional outbursts
Doesn't allow others to join in play
Has difficulty making friends
Plays with peers
Only plays with adults
Prefers to play alone
Has difficulty with separations
Has poor eye contact
Feeding
Describe Any Feeding Problems
Other: please describe
Food Likes Food Dislikes
Feeding Milestones
When did the child begin? Age (in months) Milestone Age (in months)
Using a Bottle Using a Straw Using a Pacifier Stop Using a Bottle Eating baby food Stop Using a Pacifier Eating junior food Using Utensils to Eat Eating table food Holding own bottle/cup Drinking from a Cup Self-feeding Drinking from a Sippy Cup
Breast Feeding
# times currently breast fed per day Weaned from breast feeding at age:
Was never breast fed
Current Feeding Adaptations
Thickened Liquids: Consistency:
Adapted Utensils Details:
Adapted seating
Calorie supplements
Details:
Details:
Tube Feeding
Areas of Difficulty
Amount: Times per day: Continuous Bolus
Chewing
Communication Needs
Speech Language
Drooling
Swallowing
Transitioning Between Foods
Understanding Words
Jaw shifts/slides/juts
Communication Skills
Does the child: Yes No
Have speech that is understood by most people? Respond correctly to yes/no questions? Follow simple instructions? Respond when name is called? Stutter? Recognize objects, people, and places?
Speech Milestones
When did the child begin? Age (in months) Milestone Age (in months)
Babbling Putting 2 words together Saying first words Using short sentences Naming familiar objects
First Words
Augmentative Communication Device
Primary Communication
Methods of communication used:
Verbal Non-Verbal None
Vocalizations 2 word Phrases Facial Expressions Manual Sign Language Pointing
Single Words Complete Sentences Body Language Gestures Eye Gaze
Please describe current speech concerns:
Home Environment
Child lives with: (Please select all that apply)
Birth mother
Birth father
Adoptive mother
Adoptive father
Legal guardian
Please specify:
Step-mother
Step-father
Grandmother
Grandfather
Siblings
Please list siblings ages:
other relative
Please specify:
Additional Comments:
Adoption
Age at adoption:
Additional Details:
Type of Home
Single Level
2 Level
Ground Floor Apartment
Upper Level Apartment
Assisted Living Facility
Skilled Nursing Facility
Group Home
Other
Accessibility
# Stairs to get into home:
Ramp to get into home? Yes No
Handrail? Right Left
None
# Stairs in home: Handrail? Right Left None
Bathroom on Main Level
Bathroom on Upper Level
Bedroom on Main Level
Bedroom on Upper Level
Additional Comments:
Equipment Approx. Age Details Uses at Home Uses at School/Day Care
Therapy Services Type Status How often? Where?
Equipment presently used (Please select all that apply)
Equipment: Approx. Age Details Uses at Home Uses at School/Day Care
Braces Walker Stander Manual Wheelchair Power Wheelchair Hoyer Lift Weighted Vest Hand Splint(s) Track System Other:
Describe any home program that is currently performed (e.g. stretching, strengthening, brushing, etc)
Describe any community groups or sports activities the child is involved in
Grade in School Name of School
Does your child have an IFSP?
Yes No
Does your child have an IEP from school? Yes No
Has your child had a psychological or neuropsychological evaluation completed? Yes No
Therapy Services Type Status How Often? Where?
Assistive Technology Audiology Behavior Therapy Developmental History EI Services Intensive Suit Therapy Vision Therapy Nutrition Occupational Therapy Physical Therapy Social Therapy Speech / Language Therapy Developmental Follow-up Clinic Other:
Additional Comments:
Rev. 7/2016 JPS
PARENT RIGHTS: STUDENT RECORDS
As a parent, The Family Educational Rights and Privacy Act (FERPA) affords you certain rights with respect to your
student’s education records. These rights are:
1. The right to inspect and review the student’s education records within 45 days of the day the school receives arequest for access. You must submit a written request to the principal that identifies the record(s) you wish toinspect. The principal will make arrangements for access and notify you of the time and place where the records
may be inspected.
2. The right to request the amendment of the student’s education record that you believe is inaccurate or misleading.You must write the principal, clearly identify the part of the record you want changed, and specify why it isinaccurate or misleading. If the school decides not to amend the record as requested, the school will notify you orthe decision and advise you of your right to a hearing regarding the request for amendment.
3. The right to consent to disclosure of personally identifiable information contained in the student’s educationrecords, except to the extent that FERPA authorizes disclosure without consent. Once exception, which permitsdisclosure without consent, is disclosure to school officials with legitimate educational interests. A school official
is a person employed by the district as an administrator, supervisor, instructor, or school staff; the person electedto the school board; or, a person or company with whom the district has contracted to perform a specific task. Aschool official has a legitimate educational interest if the official needs to review an education record in order tofulfill his or her professional responsibility. Personally identifiable information will be released without consent toappropriate officials in emergency situations, to comply with a lawfully issued subpoena and in cases involvingcompulsory school attendance and child abuse.
4. The right to file a complaint with the U.S. Department of Education concerning alleged failures by the school to
comply with the requirements of FERPA. The address of the Office that administers FERPA is: Family Policy
RELEASE OF DIRECTORY INFORMATION
The School District may release the following “directory information” without your permission unless you notify the principal, in writing, within ten (10) calendar days of the receipt of this public notice.
Directory Information: Student’s name, address, grade level (if junior or senior), dates of attendance, participation in school sponsored activities and sports, weight and height of members of athletic teams, and awards and honors received. (Military recruiters may also obtain telephone numbers of high school students.)
Under the provisions of the Family Educational Rights and Privacy Act, you have the right to withhold the release of the directory information listed above. If you decide that you do not want the school to release the information listed above, any future requests for the “directory information” from individuals, organizations or other entities not
affiliated with the school or district will be refused. Please indicate here your request to withhold the items listed
above.
I do not want my child’s directory information released as described above.
Parent Name: Parent Signature:
Student Name: Grade: Date___________________
If the form is not received by the school principal within ten (10) calendar days, it will be assumed that the above information may be released for the remainder of the school year.
of Rights Records
The answers to this residency questionnaire help in determining eligibility of services that may be received through the federal McKinney-Vento Homeless Assistance Act 42 U.S.C. 11435. The OCPS MVP office: 407-317- 3485; www.homeless.ocps.net
Section A: Housing is Fixed, Regular, and Adequate
Please DO NOT complete this form, if you currently: • Rent/own your home OR Live with someone by choice (not due to financial hardship)
Section B: Housing is NOT Fixed, Regular, and Adequate (Complete all sections below and return to school)
Student(s) Current Nighttime Residence:
In an emergency/transitional shelter (A) Temporarily with another family due to loss of housing, economic hardship, or
similar reason (B) In a vehicle of any kind, trailer park or campground, abandoned building or
other substandard housing (D) � In a hotel/motel due to loss of housing, economic hardship, or similar reason (E)
How long have you been at this temporary residence? ________________________
Cause of Temporary Residence:
Foreclosure (M) Natural Disaster Type:
_____________________________ � Other: (Please Explain)
_____________________________
Section C: Student Information (All OCPS students including pre-school children living together as indicated above)
Student Name Student ID# M/F DOB Grade School
Current Street Address:_____________________________________________ City: _____________________ Zip: ______________
Contact Phone Number: _________________________________ Email: _________________________________________________
Name of Parent(s) / Legal Guardian(s): ________________________________________________________________________________
Section D: Unaccompanied Homeless Youth Must Complete This Section (U)
Student is living with an adult that is not a parent or legal guardian.
Caregiver Name: _____________________________________________________
Relationship to student: ________________ Phone: _____________________
Student is living alone without an adult.
How long has the student been living alone? _____________________________________
Additional protective rights and services may be available to qualified families. These rights include immediate school enrollment, free meals, school stability, and transportation to the school of origin (if over 2 miles).
� Please check if you allow this information to be released to social service agencies for possible assistance. Expires 6/30/18
The undersigned certifies that the information provided is accurate.
_________________________________________________________________________ ___________________________
Signature of Parent/Legal Guardian (OR) Unaccompanied Homeless Youth Date
Florida Statutes 837.06 provides that whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his official duty shall be guilty of a misdemeanor of the second degree.
Student Residency Questionnaire