2012-13 vava efp
TRANSCRIPT
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Enrollment Forms Packet (EFP)Please review the information below. Based on your student(s) grade and applicable circumstances, you are required to
submit documentation in order to complete this step in the enrollment process. You can fax, scan and email, or mail the
required paperwork .
Important Note: Please send copies, do not mail the original documents
Fax (preferred): Scan and Email: Mail:
1-877-843-5902 [email protected] Virginia Virtual Academy
2300 Corporate Park DriveSuite 200Herndon, VA 20171
Virginia Virtual Academy - A program o
the Carroll County School District
Enrollment Processing Center
2300 Corporate Park Drive
Suite 200
Herndon, VA 20171
Ph. 1.877.382.6514
Fx. 1.877.843.5902
www.k12.com/vava
Required For? Item Description Provided by?
Required or all
Students
Proo o Age Ocial Birth Certifcate (not the hospital issued certifcate) Provided by you
Proo o ResidencyDrivers License, Utility bill showing current address OR Mortgage Statement/
Rental contract including signature page.Provided by you
Hearing, Vision and
Immunization
Part 1. This section is flled out by the Parent/Guardian. Part 2. This orm is
completed by your students physician. Part 3. This orm is completed by your
students physician.
Provided in this
packet
Notifcation o O-
ense FormPlease complete and submit.
Provided in this
packet
Family Income
FormPlease complete and submit.
Provided in this
packet
Home Language
Survey
Please complete and submit.Provided in this
packetSchool Ethnicity
SurveyPlease complete and submit.
Provided in
packet
Release o Records
By flling out this orm, you are giving our school permission to request your
students ocial records rom their previous school ater the approval process.
I your child is enrolling in Kindergarten or was Homeschooled please indicate it
on the orm, fll out the top portion and sign it.
Provided in this
packet
Required or all
students residing
outside o the Car-
roll County School
District
Application or
Admission as a
Non-Resident
Please complete and submit.Provided in this
packet
Required or
student with anIEP or other Special
Education needs
IEP
A copy o your students current IEP (Individualized Education Plan). Because
the IEP expires yearly, please submit the current IEP. Provided by you
Evaluation ReportThe Evaluation Report is valid or 3 years. I you do not have a copy o your
students ER, you can request a copy rom your students current school.Provided by you
Required or stu-
dents that have a
504 plan
504 Accommoda-
tion Plan
A copy o your students current 504 Accommodation Plan. Because the 504
expires yearly, please submit the current 504.Provided by you
mailto:vavafax%40k12.com?subject=Student%20Name%3Ahttp://www.k12.com/vava/http://www.k12.com/vava/mailto:vavafax%40k12.com?subject=Student%20Name%3A -
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MCH 213 G r evised 10/2010 1
COMMONWEALTH OF VIRGINIASCHOOL ENTRANCE HEALTH FORM
Health Information Form/Comprehensive Physical Examination Report/Certification of Immunization
Part IHEALTH INFORMATION FORM
State law (Ref. Code of Virginia 22.1-270) requires that your child is immunized and receives a comprehensive physical examination before entering public
kindergarten or elementary school. The parent or guardian completes this page (Part I) of the form. The Medical Provider completes Part II and Part III of the
form. This form must be completed no longer than one year before your childs entry into school.
Name of School: ____________________________________________________________________________________ Current Grade: _______________________
Students Name: _________________________________________________________________________________________________________________________
Last First Middle
Students Date of Birth: _____/_____/_______ Sex: _______ State or Country of Birth: ________________________ Main Language Spoken: ______________
Students Address: ______________________________________________________ City: ____________________ State: _______________ Zip: _______________
Name of Mother or Legal Guardian: ______________________________________________ Phone: ______ -______-________ Work or Cell: _____-_____-______
Name of Father or Legal Guardian: ______________________________________________ Phone: ______ -______-________ Work or Cell: _____-_____-______
Emergency Contact: __________________________________________________________ Phone: ______ -______-________ Work or Cell: _____-_____-______
Condition Yes Comments Condition Yes Comments
Allergies (food, insects, drugs, latex) DiabetesAllergies (seasonal) Head injury, concussions
Asthma or breathing problems Hearing problems or deafness
Attention-Deficit/Hyperactivity Disorder Heart problems
Behavioral problems Lead poisoning
Developmental problems Muscle problems
Bladder problem Seizures
Bleeding problem Sickle Cell Disease (not trait
Bowel problem Speech problems
Cerebral Palsy Spinal injury
Cystic fibrosis Surgery
Dental problems Vision problems
Describe any other important health-related information about your child (for example, feeding tube, hospitalizations , oxygen support, hearing aid, etc.):
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
List all prescription, over-the-counter, and herbal medications your child takes regularly:
_______________________________________________________________________________________________________________________________________
Check here if you want to discuss confidential information with the school nurse or other school authority. Yes No
Please provide the following information:
Name Phone Date of Last Appointment
Pediatrician/primary care provider
Specialist
Dentist
Case Worker (if applicable)
Childs Health Insurance: ____ None ____ FAMIS Plus (Medicaid) _____ FAMIS _____ Private/Commercial/Employer sponsored
I, ______________________________________ (do___) (do not___) authorize my childs health care provider and designated provider of health care in theschool setting to discuss my childs health concerns and/or exchange information pertaining to this form. This authorization will be in place until or unless you
withdraw it. You may withdraw your authorization at any t ime by contacting your childs school. When information is released from your childs record,documentation of the disclosure is maintained in your childs health or scholastic record.
Signature of Parent or Legal Guardian: ______________________________________________________________________Date: _______/________/ __________
Signature of person completing this form: ____________________________________________________________________Date:_______/________/___________
Signature of Interpreter: ____________________________________________________________________ ______________Date: ______/_____/_______
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MCH 213 G r evised 10/2010 2
COMMONWEALTH OF VIRGINIA
SCHOOL ENTRANCE HEALTH FORM
Part II - Certification of Immunization
Section I
To be completed by a physician or his designee, registered nurse, or health department official.
See Section II for conditional enrollment and exemptions.
A copy of the immunization record signed or stamped by a physician or designee, registered nurse, or health department
official indicating the dates of administration including month, day, and year of the required vaccines shall be acceptable
in lieu of recording these dates on this form as long as the record is attached to this form.
Only vaccines marked with an asterisk are currently required for school entry. Form must be signed and dated by the
Medical Provider or Health Department Official in the appropriate box.
Certification of Immunization 11/06
Students Name: Date of Birth: |____|____|____|
Last First Middle Mo.Day Yr.
IMMUNIZATION RECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN
*Diphtheria, Tetanus, Pertussis (DTP, DTaP) 1 2 3 4 5
*Diphtheria, Tetanus (DT) or Td (given after 7
years of age) 1 2 3 4 5
*Tdap booster (6th grade entry) 1
*Poliomyelitis (IPV, OPV) 1 2 3 4
*Haemophilus influenzae Type b
(Hib conjugate)
*only for children
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MCH 213 G r evised 10/2010 3
Students Name: Date of Birth: |____ |_ ___|___ _|
Section IIConditional Enrollment and Exemptions
Complete the medical exemption or conditional enrollment section as appropriate to include signature and date.
Certification of Immunization 10/2010
MEDICAL EXEMPTION: As specified in the Code of Virginia 22.1-271.2, C (ii), I certify that administration of the vaccine(s) designated below would bedetrimental to this students health. The vaccine(s) is (are) specifically contraindicated because (please specify):
________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________.
DTP/DTaP/Tdap:[ ]; DT/Td:[ ]; OPV/IPV:[ ]; Hib:[ ]; Pneum:[ ]; Measles:[ ]; Rubella:[ ]; Mumps:[ ]; HBV:[ ]; Varicella:[ ]
This contraindication is permanent: [ ], or temporary [ ] and expected to preclude immunizations until: Date (Mo., Day, Yr.): |___|___|___|.
Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.):|___|___|___|
RELIGIOUS EXEMPTION: The Code of Virginia allows a child an exemption from receiving immunizations required for school attendance if the student or the
students parent/guardian submits an affidavit to the schools admitting official stating that the administration of immunizi ng agents conflicts with the students religio
tenets or practices. Any student entering school must submit this affidavit on a CERTIFICATE OF RELIGIOUS EXEMPTION (Form CRE-1), which may be obtaineany local health department, school division superintendents office or local department of social services. Ref. Code of Virginia 22.1-271.2, C (i).
CONDITIONAL ENROLLMENT: As specified in the Code of Virginia 22.1-271.2, B, I certify that this child has received at least one dose of each of the vaccine
required by the State Board of Health for attending school and that this child has a plan for the completion of his/her requirements within the next 90 calendar days. N
immunization due on __________________.
Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.):|___|___|___|
For Minimum Immunization Requirements for Entry into School and
Day Care, consult the Division of Immunization web site at
http://www.vdh.virginia.gov/epidemiology/immunization
Children shall be immunized in accordance with the Immunization Schedule developed and published bthe Centers for Disease Control (CDC), Advisory Committee on Immunization Practices (ACIP), the
American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP),
otherwise known as ACIP recommendations (Ref. Code of Virginia 32.1-46(a)).
(requirements are subject to change.)
Section III
Requirements
http://www.vdh.virginia.gov/epidemiology/immunizationhttp://www.vdh.virginia.gov/epidemiology/immunization -
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MCH 213 G r evised 10/2010 4
Part III -- COMPREHENSIVE PHYSICAL EXAMINATION REPORT
A qualified licensed physician, nurse practitioner, or physician assistant must complete Part III . The exam must be done no longer than one year before entry
into kindergarten or elementary school (Ref. Code of Virginia 22.1-270). Instructions for completing this form can be found at www.vahealth.org/schoolhealth
Students Name: _______________________________________________ Date of Birth: _____/_____/__________ Sex: M F
HealthAssessment
Date of Assessment: _____/_____/_______
Weight: ________lbs. Height: _______ ft. ______ in.
Body Mass Index (BMI): ___________ BP____________
Age / gender appropriate history completed
Anticipatory guidance provided
TB Risk Assessment: No Risk Positive/ReferredMantoux results: __________________mm
Physical Examination
1 = Within normal 2 = Abnormal finding 3 = Referred for evaluation or treatment
1 2 3 1 2 3 1 2 3
HEENT Neurological Skin
Lungs Abdomen Genital
Heart Extremities Urinary
EPSDT Screens Required for Head Startinclude specific results and date:Blood Lead:___________________________________________ Hct/Hgb ____________________________________________
Developmental
Screen
Assessed for: Assessment Method: Within normal Concern identified: Referred for Evaluation
Emotional/Social
Problem Solving
Language/Communication
Fine Motor Skills
Gross Motor Skills
Hearing
Screen
Screened at 20dB: Indicate Pass (P) or Refer (R) in each box.
1000 2000 4000
R
L
Screened by OAE (Otoacoustic Emissions): Pass Refer
Referred to Audiologist/ENT Unable to testneeds rescreen
Permanent Hearing Loss Previously identified: ___Left ___Right
Hearing aid or other assistive device
Vision
Screen
With Corrective Lenses (check if yes)
Stereopsis Pass Fail Not tested
Distance Both R L Test used:
20/ 20/ 20/
Pass Referred to eye doctor Unable to testneeds rescreen
Dental
Screen
Problem Identified: Referred for treatment
No Problem: Referred for prevention
No Referral: Already receiving dental care
Recommen
dat
ions
to(Pre
)Sc
hoo
l,
ChildCare,
or
Ear
ly
Interven
tion
Personne
l
Summary of Findings (check one):
Well child; no conditions identified of concern to school program activities
Conditions identified that are important to schooling or physical activity (complete sections below and/or explain here): ____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
___ Allergy food: _____________________ insect: _____________________ medicine: _____________________ other: _________________Type of allergic reaction: anaphylaxis local reaction Response required: none epi pen other: _______________________________
___Individualized Health Care Plan needed (e.g., asthma, diabetes, seizure disorder, severe allergy, etc)
___ Restricted Activity Specify: _________________________________________________________________________________________________
___ Developmental Evaluation Has IEP Further evaluation needed for: ___________________________________________________________
___ Medication. Child takes medicine for specific health condition(s). Medication must be given and/or available at school.
___ Special Diet Specify: ______________________________________________________________________________________________________
___ Special Needs Specify: ______________________________________________________________________________________________________
Other Comments: _____________________________________________________________________________________________________________
Health Care Professionals Certification (Write legibly or stamp):
Name : _____________________________________ Signature:________________________________________ Date: ____/_____/______
Practice/Clinic Name: __________________________________________ Address: ____________________________________________________________
Phone: _______-_______-____________________ Fax: _______-_______-_____________________ Email: _________________________________________
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Virginia Virtual Academy - A program o
the Carroll County School District
Enrollment Processing Center
2300 Corporate Park Drive
Suite 200
Herndon, VA 20171
Ph. 1.866.654.8297
Fx. 1.877.843.5902
www.k12.com/vava
Notification of Offense Form
Parental Registration Statement:
Student Name:
Date o Birth: Grade:
Please choose one o the ollowing options and sign:
1. I, __________________________, arm that my student, _________________________, was NOT previously suspended or ex-
pelled rom any public or private school o this Commonwealth or any other State or an act or oense involving weapons, alcoho
or drugs, or or the willul infiction o injury to another person or any act o violence committed on school property.
OR
2. I, __________________________, arm that my student, _________________________, WAS previously suspended or expelled
rom any public or private school o this Commonwealth or any other State or an act or oense involving weapons, alcohol or
drugs, or or the willul infiction o injury to another person or any act o violence committed on school property. My student was
suspended or expelled rom the ollowing school(s):
My student was (check one o the ollowing)o suspended or o expelled rom the ollowing school(s):
School Name: ______________________________________________________________
Address: __________________________________________________________________
Telephone Number: _________________________________________________________
Expulsion/Suspension Start Date_________________
Expulsion/Suspension End Date__________________
My student was suspended or expelled or the ollowing reason(s):
(Please check all that apply)
o oense involving weapons
o oense involving alcohol
o oense involving drugs
owillul infiction o injury to another person
o
an act o violence committed on school propertyo other (please note below)
Additional comments: _________________________________________________________
Signature ______________________________________________Date _______________
Students Name: Students Home Phone:1
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Carroll County Public Schools
Student Home Language Survey
Students Name: __________________________________________ Date: _____________________________
Grade: _____________ Teacher: __________________________ School: _____________________________
Relationship of Person Completing Survey:
Mother Father Guardian Other (specify): _______________________________
Check the best answer to each question:
1. Was the first language learned by the student English? Yes No
2. Can the student speak languages other than English? Yes No
Which other languages? __________________________________________
3. Which language does the student use most often when speaking to friends?
English Other language: ___________________________
4. Which language does the student use most often when speaking to his/her parents?
English Other language: ___________________________
5. Does anyone in your home speak a language other than English? Yes No
Which other language? ___________________________________________
6. Have you moved in order to obtain agriculture work in the past 36 months? Yes No
7. In what country was the student born? ___________________________________
8. Is the student: US Citizen Immigrant Refugee
_________________________________________________ _____________________________________
Parent Name Print Date
_________________________________________________ _____________________________________
Parent or Guardian Signature Date
Office use only:
o If the answer to Number 2 is yes, and other languages are given as answers to numbers 3, 4, or 5,the students English abilities should be tested even if the students oral ability is good. In this case, a
copy of this form should be given to the schools ESL teacher and the divisions ESL coordinator.
o One copy of this form should be kept in the students permanent record.
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Carroll County Public Schools Ethnicity Survey
Please Print
Students Last Name
Students First Name
Students Middle Name
Students Current Grade
Students Current School
Part A and Part B must be completed
Part A. Is this student Hispanic/Latino?(Choose only one)
No, Not Hispanic/Latino
Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American,or other Spanish culture or origin, regardless of race.)
The above part of the question is about ethnicity, not race. No matter what you selected above,
please continue to answer the following by marking one or more boxes to indicate what you
consider your students race to be.
Part B. What is the students race? (Choose one or more)
American Indian or Alaska Native(A person having origins in any of the original peoples ofNorth and South America (including Central America), and who maintains tribal affiliation or
community attachment.)
Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, orIndian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia,
Pakistan, the Philippne 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 originalpeoples of Hawaii, Guam, Samoa, or other Pacific Isalnds.)
White (A person having origins in any of the original peoples of Europe, the Middle East, or
North Africa.)
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Virginia Virtual Academy - A program of
the Carroll County School District
Enrollment Processing Center
2300 Corporate Park Drive
Suite 200
Herndon, VA 20171
Ph. 1.866.654.8297
Fx. 1.877.843.5902
www.k12.com/vava
Student Information
Students Full Name:first middle last
Students Date of Birth: Students Social Security Number:
Students Legal Address:street apt #
city county state zip
Home Phone:
Check below if applicable:
o Student was always previously homeschooled
o Student is enrolling in Kindergarten
Name of Prior School:
Schools Address:street
city county state zip
Schools Phone: Schools Fax:
Name of Parent or Legal Guardian:first last
Parent/Guardians Signature: Date:
Release of Student Records
Please accept this document as formal approval for the release of all official school records (including the record of transcripts, testing information,special education, health and immunization records).
Homeschooled or Never Previously Enrolled in School (Fill out only if applicable)
Prior School Information
Sign and Date below
SCHOOL OFFICIALS ONLY:
Send student records to: Virginia Virtual Academy
Enrollment Processing Center
2300 Corporate Park Drive, Suite 200
Herndon, VA 20171
Students Name: Students Home Phone:7
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CARROLL COUNTY PUBLIC SCHOOLS
605-9 PINE STREET
HILLSVILLE, VIRGINIA 24343
(276) 728-3191
(276) 236-8145
APPLICATION FOR ADMISSION AS A NON-RESIDENT STUDENT
For School Year ________________
Students Name _________________________________________________________________
LAST FIRST MIDDLE
Date of Birth _______________________________ Age ______ Male ____ Female ____
MONTH DAY YEAR
Name of Parent(s) or Legal Guardian(s) __________________________________________________
Current Legal Address (911) ___________________________________________________________
Mailing Address ____________________________________________________________________
Home Telephone ____________________ Work Telephone _____________ Cell ________________
County or City of Residence ___________________
Name, Address, and Telephone Number of School Last Attended By Student:
_____________________________________________________________
_________________________________________________________________________________________________________________________
Reason for Leaving Previous School:__________________________________________________________________________________
If the Student Has Been Enrolled in Any Special Education Programs in the School(s) Last Attended,
Please Specify: ______________________________________________________________________
School Requesting to Attend: __________________________________ Grade: _________________
Why Do You Wish to Enroll Your Child in Carroll County Public Schools?
__________________________________________________________________________________
I certify that the information in this application is true and accurate to the best of my knowledge
and that I have been provided, read, understood, and signed the Student School Assignment
Guidelines.
____________________ _______________________________________
Date Signature of Parent/Guardian
I affirm that the above name student has not been suspended or expelled from school attendance
at a private or public school nor has been assigned to any correctional facility or placed on
probation by the court system.
____________________ _______________________________________
Date Signature of Parent/Guardian (OVER)
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CARROLL COUNTY PUBLIC SCHOOLS
STUDENT SCHOOL ASSIGNMENTS
NON-RESIDENT STUDENT REQUESTS
Consideration of a request to register a non-resident student from another school division in Virginia is contingent
upon the following:
1. Completion of an APPLICATION FOR ADMISSION AS A NON-RESIDENT STUDENT. Applications must be
returned to the Office of the Division Superintendent.
2. Availability of space in the grade level and/or program which is indicated by current placement. Acceptance and/or
continued enrollment of a non-resident student will not require the initiation of a new program, the employment of additional
personnel, the alteration of existing facilities, or the payment of special services beyond those provided in the Carroll County
Public Schools. The approval of a non-resident student application will be subject to maintaining available space in a grade
level/program for students who may move into the attendance area.
3. Continued enrollment of a non-resident student is subject to annual review. All non-resident student applications
will be subject to renewal on an annual basis. Continuation applications must be received in the Office of the Superintendent
within the designated timeline otherwise the application will be processed as a new request. Continued placement in a Carroll
County School by a non-resident student will be contingent upon available space, programs, discipline, and school attendance.
Students are subject to all policies, regulations, and guidelines of the school division and the Carroll County Public Schools
Student Handbook. Notification of approval will be on an annual basis.
4. The superintendent will approve or deny non-resident student applications based upon a review of the application,
recommendation by school principal or others as necessary, and the availability of space and/or programs.
5. Approval of non-resident student status may be revoked. Non-resident students would be expected to return to the
school division in which they reside when their enrollment creates any of the conditions described above in numbers two and
three. Transfer to another school in Carroll County is subject to the same approval process.
6. Transportation of non-resident students is the responsibility of the parent or guardian. Non-resident transfer
students may board a bus at a bus stop that serves the school they have been approved to attend.
7. Any transfer request that is received and/or approved based upon false or misleading information will be
declared void and the transfer will be rescinded.
8. The superintendent reserves the right to remove the privilege to attend Carroll County Public Schools.
9. Failure to meet any of the above criteria will result in an immediate removal from Carroll County Public Schools.
_____________________ ___________________________________
DATE Signature Parent or Guardian
OUT OF STATE STUDENT REQUESTS
Consideration of a request to register a non-resident student from another state is contingent upon the following:
1. All criteria set forth in aforementioned non-resident guidelines of student school assignments.2.
Payment of any applicable tuition charges prior to enrollment.
3. If, for any reason, the parent does not remit tuition within the prescribed time limit, the approval for transfermay be rescinded. If payment is not made, determination for future enrollment as a transfer student will be
denied.
_____________________ ___________________________________
DATE Signature Parent or Guardian
ADOPTED: 08/04/93
03/29/05
10/10/06