enrollment package 2015-2016 pre-kindergarten only · revised march 2015 swps registration...

Revised March 2015 SWPS Registration Application

1

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)


2


3

1

Southwest Preparatory School

Student Enrollment Information

Date of Enrollment ____/____/____

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 #:_____________________________ Date 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 (1st Parent is always the parent enrolling student) First, MI, Last Name

1st Prnt/Grdn Relationship: ____________________________2nd Prnt/Grdn Relationship: _________________________

2nd 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


4

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: _____________



Parent Signature: _______________________________________ Date: ________________________

Student Signature: _______________________________________ Date:________________________


5

2


Emergency Physician and Care Authorization

_________________________________________________ _____ ______ ___________ Student Name (Last) (First) (MI) Sex Grade Date 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) Past Health Problems: (Check All That Apply)

Cardiac_____ Chicken Pox _____

Asthma_____ Hepatitis _____ A _____ B _____Other_____ Diabetes_____ Mononucleosis_____

Seizure Disorder_____ Surgery (Describe)_________________________________

Blood Disorder_____ ________________________________________________ Other________________________________________________________ ________________________________________________

Severe Drug Allergy_______ ________________________________________________

Name Of Drug And Reaction___________________________________ ________________________________________________ Is Breathing Affected? Yes___ No____ Other:___________________________________________

Severe Food Allergy_________ ________________________________________________

Name Of Food & Reaction_____________________________________ Medications Taken On A Regular Basis: Is Breathing Affected? Yes____ No____ ________________________________________________

Severe Insect Bite Allergy_______ ________________________________________________

Name Of Insect & Reaction____________________________________ ________________________________________________ Is Breathing Affected Yes____ No____ Other Health Problems/Concerns:

Vision Problem_________ _______________________________________________

Type______________________________________________________ _______________________________________________ Glasses Or Contacts? Yes_____ No_____ _______________________________________________

Hearing Problem_________ Date of Last Tetanus Booster:_____________________

Type/Cause_________________________________________________ Hearing Aid Appliance? Yes___ No___

Hearing Loss: Permanent_____ Temporary______

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_______________________________________________________________ Date_____________________


6

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:______________________________________ Date of Birth:________________

Grade:_________ School:________________________________________________________

Parent/Guardian Name:___________________________________________________________

Work Phone:_______________ Mobile Phone:_______________ Home phone:_____________

Parent/Guardian Signature___________________________________ Date:________________

Date form received by School Campus:______________________________________________


7

4


Lottery System Acknowledgement

Dear Student/Parent/Guardian:

Lottery System

Southwest Preparatory School (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-first-

serve basis.

Please complete the “Acknowledgment” section of this letter below. Thank you for complying with the

Lottery System.

Sincerely,

Southwest Preparatory School Administration

Acknowledgement: I hereby acknowledge that I have read and understand the SWPS Lottery System.

__________________________________________________

Print Student’s Full Name

______

Student’s Signature Date

__________________________________________________

Print Parent/Guardian Full Name

Parent/Guardian Signature Date


8

5


Enrollment Verification

Southwest Preparatory School 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, Southwest Preparatory School will serve the following student

population.

1. Students who are at least 3 years old or have not reached their 26th 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 Date Student Date of Birth

_____________________________ _______________

Parent Signature Date

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


9

6


Parent/Student Handbook & Code of Conduct Acknowledgement

Dear Student/Parent/Guardian:

The Southwest Preparatory School 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 Southwest Preparatory School

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,

Southwest Preparatory School Administration

We acknowledge that we have received a copy of the Southwest Preparatory School 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 Date

____________________________________________________________________


____________________________________________________________________


http://www.swprep.org/


10

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 Southwest Preparatory School (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 Date

_________________________________ _____________

Signature of Parent or Guardian Date


11

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.

____________________________________________________________________


____________________________________________________________________


For Office Use Only

PEIMS Coding

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 Date


12

Date: District: Campus:

Student Name: Date 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)

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:

9

Fruit, vegetables, sunflower, cotton, wheat,

grain, on farms or ranches, fields & vineyards

2015-2016 Family Survey


13

10


Student Residency Questionnaire

Name of Student: ____________________________________ Sex: Male Female

Date 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 Date

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 Date


14

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)

________________________________

(Parent/Guardian)/(Staff) Signature

________________________________

Student/Staff Identification Number

________________________________ Date

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: _____ Hispanic / Latino _____ Not Hispanic/Latino

Race – choose one or more: _____ American Indian or Alaska Native _____ Asian _____ Black or African American _____ Native Hawaiian or Other Pacific Islander _____ White

Observer signature:

Campus and Date:

Texas Education Agency – March 2010 (last update)


15

12


Home Language Survey

Student Name: ____________________________________________________________

School: Southwest Preparatory 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? ____________________________

_______________________________________ ____________________


What language do you prefer to recieve coorespondance from the school in? ______________________

Quetionario De Idioma Hogarido

Nombre del Estudiante: __________________________________________________

Escuela: Southwest Preparatory School 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 Date scanned

Student enrolling in a Texas public school for the first time.

enrollment package 2015-2016 pre-kindergarten only · revised march 2015 swps registration...

Documents