Enrollment Forms Packet (EFP)

Required For? Item Description Provided by?

Required for all Students

Proof of Age Official Birth Certificate (not the hospital issued certificate) OR Baptismal Re-cords

Provided by you

Proof of Residency

Please sumbit two of the following items: Current utility bill, Illinois driver’s license or State of Illinois identification card, deed, employer identification card, MediPlan/Medicaid card, voter registration card, court documents, Illinois De-partment of Public Aid card, stamped USPS change of address form, Illinois state aid check/social security check, other identification card issued by a federal or state agency or foreign government consulate such as the Matricula Consular.

Provided by you

Report Card The most recent Report Card, except for students enrolling in Kindergarten. Provided by you

Immunization Record and Medical Form

Please have forms filled out by your students physician and submit to CVCS. Provided in this packet

CPS Student Medical Information Form

In order to ensure the safety of your student during the school year, extracur-ricular activities, and on any field trips, we are asking y ou to please complete this form. For confidential purposes, this information will only be shared with relevant CVCS/CPS Staff.

Provided in this packet

Student Transporta-tion Form

To ensure the safety of your child, CVCS requires that you confirm how your stu-dent will be getting to and from the Learning Center each week. This informa-tion will also be on each student’s ID card so CVCS staff knows exactly how each student will safely leave the building.

Provided in this packet

Release of Records

By filling out this form, you are giving our school permission to request your student’s official records from their previous school after the approval process. If your child is enrolling in Kindergarten or was Homeschooled please indicate it on the form, fill out the top portion and sign it.

Provided in this packet

Home Language Survey A list of Home Language Codes is also provided to use as a reference guide. Provided in this

packet

Required for all 10 -11th Grade Students

Unofficial Tran-scripts

You will need to request an unofficial transcript from your student's current school, which will show your student’s academic standing. This is required in order to place all 10th and 11th graders. Once your student is approved, we will receive the official transcript.

Provided by you

Required for student with an IEP or other Special Education needs

IEP A copy of your student’s current IEP (Individualized Education Plan). Because the IEP expires yearly, please submit the current IEP.

Provided by you

Evaluation Report The Evaluation Report is valid for 3 years. If you do not have a copy of your student’s ER, you can request a copy from your student’s current school.

Provided by you

Required for stu-dents that have a 504 plan

504 Accommoda-tion Plan

A copy of your student’s current 504 Accommodation Plan. Because the 504 expires yearly, please submit the current 504.

Provided by you

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 will need to bring these documents in person to be reviewed by a CVCS administrator, do not fax or mail these into CVCS and make sure you bring originals for review. Our address is below:

Chicago Virtual Charter School 38 S. Peoria Street Chicago, Il 60607 Office Hours Mon-Fri 8 AM-4PM

Chicago Virtual Charter SchoolEnrollment Processing Center 38 S. Peoria Street Chicago, Il 60607

Ph. 866.467.6186 www.k12.com/cvcs

Student Transportation Form To ensure the safety of your child, CVCS requires that you confirm how your student will be getting to and from the Learning Center each week. This information will also be on each student’s ID card so CVCS staff knows exactly how each student will safely leave the building. Thank you in advance for your help and cooperation. Student Name (Last, First): _______________________________________________________________ Learning Coach Name (Last, First): ________________________________________________________ Learning Coach Phone Number: ___________________________________________________________ Emergency Contact Name and Number: _____________________________________________________

Only one box should be checked: Please indicate how your child will be getting to and from the Learning Center each week.

Parent/guardian will drop off/pick up student at the side door of the school

Student will carpool with a friend/neighbor and will be picked-up at the side door of the school Name of friend/neighbor: ____________________________________

Student will be picked up by a friend/neighbor and will wait in the CVCS Parent Room

Name of friend/neighbor: ____________________________________

Parent/guardian will wait in the CVCS Parent Room

Student will be taking public transportation (CTA bus or train) Please list three adults (over the age of 18) that you allow to pick up your student(s) early from school. Identification must be shown for all adults listed below: 1. ______________________________________________________ __________________________ Last Name First Name Relation to Student Phone Number 2. ______________________________________________________ __________________________ Last Name First Name Relation to Student Phone Number 3. ______________________________________________________ __________________________ Last Name First Name Relation to Student Phone Number ________________________________________________________ ______________________ Parent/Guardian Signature Date

REQUEST FOR STUDENT RECORDS

(This section to be filled out by parent): Name of school currently holding student records: ____________________________________________________ School Phone Number: ___________________________ School Fax Number: _____________________________ Street Address: __________________________________________________________________ City, State, Zip: __________________________________________________________________ (This section to be filled out by CVCS): Dear School Official: Date: ______________________________ The following student has enrolled at Chicago Virtual Charter School for the 2011-2012 school year: Name: __________________________________ ID Number: ______________________________ Date of Birth: _____________________________ Please send the following records pertaining to the aforementioned student:

• Cumulative Records Card • Cumulative Folder • Medical Folder • Individualized Learning Plan (if applicable) • Special Education Records (504 or IEP, or School Based Problem Solving file)

Please forward records to: Chicago Virtual Charter School or CPS Mail Run/GSR 38 Attn: Alissa Solomon – Operations Assistant 38 South Peoria Street Chicago, Illinois 60607

Should you have any questions, please contact Alissa Solomon, Operations Assistant, at 312.267.4486. Public Law 90-380 regarding the “Release of School Records” was modified by SB-182, Article 5, to permit schools to send educational records to other schools without the written consent of parents, guardians, or eligible students.

c/o Merit School of Music 38 South Peoria Street Chicago, Illinois 60607 312-267-4486 Phone 877-257-4609 Fax www.chicagovcs.org

Complete this Home Language Survey at the student’s initial enrollment in Chicago Public Schools. (This form must be kept in the student’s folder.)

School: Room: Unit: Area:

Student Name: Student ID No.:

English 1. Is a language other than English spoken at home?

No Yes (Language)

2. Does the student speak a language other than English?

No Yes (Language)

Spanish Polish

1. ¿Se habla algún otro lenguaje que no sea ingles en el hogar?

1. Czy językiem innym niż angielski mówi się w domu?

No Sí (Lenguaje) Nie Tak (język)

2. ¿Habla el estudiante un lenguaje que no sea el inglés? 2. Czy uczeń mówi innym językiem niż angielski?

No Sí (Lenguaje) Nie Tak (język)

Chinese Arabic

Bosnian/Croatian/Serbian Urdu

Chicago Public Schools

Signature of Parent/Guardian Date Signature of School Official Date

Office of Language and Cultural Education

Revised: Dec 2007

Notes: • The school staff who enrolls the student is required to obtain answers from the parent/legal guardian • If the parent/guardian does nor speak English and the school does not have staff who speaks the parent/guardian’s language, identify

the language spoken by the parent/guardian through any assistance available in the school (including students). • If exact name of the language cannot be determined, enter the code for “Other” (099) as a temporary entry. The exact language must be

determined within two weeks after the enrollment. Assistance from Area Compliance Facilitators is available. • If multiple languages are specified in response to either of the two questions, ask the parent/guardian for the language of his/her choice.

***For Language Code Lists, see back.

Home Language Code

Enter the appropriate language code (from the back of this form) on this

line and in to IMPACT.

HOME LANGUAGE CODE LIST

LIST OF LANGUAGE CODE (Language Sequence) CODE LANGUAGE CODE LANGUAGE CODE LANGUAGE CODE LANGUAGE 001 SPANISH 035 RUSSIAN 072 MENOMINEE 119 KONKANI 002 GREEK 036 CEBUANO (VISAYAN) 073 CAMBODIAN (KHMER) 120 KRIO 003 ITALIAN 037 GUJARATI 074 LAO 121 KURDISH 004 POLISH 038 LATVIAN 075 SHONA 122 LINGALA 005 GERMAN 039 SIOUX (DAKOTA) 076 AFRIKAAN (TAAL) 123 LUGANDA 006 ALGONQUIN 040 NORWEGIAN 077 NEPALI 124 LUYIA (LUHYA) 007 SERBIAN 041 DANISH 078 MARATHI 125 LUNDA 008 KOREAN 042 ALBANIAN, CHEG 079 ONEIDA 126 YOMBE 009 PILIPINO (TAGALOG) (KOSOSVO/MACEDONIA) 080 HAUSAN 127 OKINAWAN 010 ARABIC 043 COMANCHE 082 PIMA 128 ORIYA 011 JAPANESE 044 FINNISH 084 PUEBLO 129 ORRI (ORING) 012 FRENCH 045 SLOVAK 085 IBO 131 PASHTO (PUSHTO) 013 SAMOAN 046 SWAHILI 086 TELUGU (TELEGU) 132 SIKKIMESE 014 HINDI 047 TAIWANESE (FORMOSAN) 087 CHOCTAW 133 SINDHI 015 BURMESE 048 CREEK 088 WINNEBAGO 134 SINHALESE 016 YIDDISH 049 HAITIAN - CREOLE 090 YORUBA 135 SOTHO 017 LITHUANIAN (049 AND 118 COMBINED) 091 MALTESE 137 TIBETAN 018 UKRANIAN 050 CHIPPEWA 093 ROMANY (GYPSY) 139 KACHE (KAJE, JJU) 019 HUNGARIAN 052 EWE 094 TAMIL 142 KPELLE 020 CZECH 053 PANJABI (PUNJABI) 095 HOPI 143 ILONGO (HILIGAYNON) 021 CANTONESE (CHINESE) 055 BULGARIAN 096 SLOVENIAN 144 EFIK 022 THAI 056 APACHE 097 CHEROKEE 146 MIEN (YAO) 023 PORTUGUESE 057 GAELIC (SCOTTISH) 098 CROW 147 CHADCHOW/TEDCHIU 024 SWEDISH 058 MACEDONIAN 102 GAELIC (IRISH) (CHINESE) 025 ASSYRIAN 059 MALAY 103 AKAN (FANTE, ASANTE) 148 FUKIEM/HOKKIEN

(SYRIAC, ARAMAIC) 060 MALAYALAM 104 TULUAU (CHINESE) (Old 113) 026 ARMENIAN 061 NAVAJO 105 AMHARIC 149 HAINANESE (CHINESE) 027 ROMANIAN 062 INDONESIAN 107 BALINESE 150 SHANGAHI (CHINESE) 028 DUTCH/FLEMISH 063 KANNADA (KANARESE) 108 CHAMORRO 151 CROATIAN 029 HEBREW 064 ESTONIAN 111 ESKIMO 152 BOSNIAN 030 MANDARIN 065 FLEMISH 113 HAKKA (CHINESE) 153 ALBANIAN, TOSK 031 FARSI (PERSIAN) 066 KASHMIRI 114 WELSH 162 MAAY 032 TURKISH 067 BENGALI 115 GUYANESE 163 KRAHN 033 URDU 068 HIMONG 116 USE 049 (Haitian) 199 MONGOLIAN 034 VIETNAMESE 070 ICELANDIC 118 PAMPANGAN 099 OTHER

LIST OF LANGUAGE CODE (Language Sequence) IN ALPHABETICAL ORDER 076 AFRIKAAN (TAAL) 064 ESTONIAN 142 KPELLE 023 PORTUGUESE 103 AKAN (FANTE, ASANTE) 052 EWE 163 KRAHN 084 PUEBLO 042 ALBANIAN, CHEG 031 FARSI (PERSIAN) 120 KRIO 027 ROMANIAN

(KOSOSVO/MACEDONIA) 044 FINNISH 121 KURDISH 093 ROMANY (GYPSY) 153 ALBANIAN, TOSK 065 FLEMISH 074 LAO 035 RUSSIAN 006 ALGONQUIN 012 FRENCH 038 LATVIAN 013 SAMOAN 105 AMHARIC 148 FUKIEM/HOKKIEN 122 LINGALA 007 SERBIAN 056 APACHE (CHINESE) (Old 113) 017 LITHUANIAN 150 SHANGAHI (CHINESE) 010 ARABIC 102 GAELIC (IRISH) 123 LUGANDA 075 SHONA 026 ARMENIAN 057 GAELIC (SCOTTISH) 125 LUNDA 132 SIKKIMESE 025 ASSYRIAN 005 GERMAN 124 LUYIA (LUHYA) 133 SINDHI

(SYRIAC, ARAMAIC) 002 GREEK 162 MAAY 134 SINHALESE 107 BALINESE 037 GUJARATI 058 MACEDONIAN 039 SIOUX (DAKOTA) 067 BENGALI 115 GUYANESE 059 MALAY 045 SLOVAK 152 BOSNIAN 149 HAINANESE (CHINESE) 060 MALAYALAM 096 SLOVENIAN 055 BULGARIAN 049 HAITIAN - CREOLE 091 MALTESE 135 SOTHO 015 BURMESE (049 AND 118 COMBINED) 030 MANDARIN 001 SPANISH 073 CAMBODIAN (KHMER) 113 HAKKA (CHINESE) 078 MARATHI 046 SWAHILI 021 CANTONESE (CHINESE) 080 HAUSAN 072 MENOMINEE 024 SWEDISH 036 CEBUANO (VISAYAN) 029 HEBREW 146 MIEN (YAO) 047 TAIWANESE/FORMOSAN 108 CHAMORRO 014 HINDI 199 MONGOLIAN 094 TAMIL 147 CHADCHOW/TEDCHIU 068 HIMONG 061 NAVAJO 086 TELUGU (TELEGU)

(CHINESE) 095 HOPI 077 NEPALI 022 THAI 097 CHEROKEE 019 HUNGARIAN 040 NORWEGIAN 137 TIBETAN 050 CHIPPEWA 085 IBO 116 USE 049 (Haitian) 104 TULUAU 087 CHOCTAW 070 ICELANDIC 127 OKINAWAN 032 TURKISH 043 COMANCHE 143 ILONGO (HILIGAYNON) 079 ONEIDA 018 UKRANIAN 048 CREEK 062 INDONESIAN 128 ORIYA 033 URDU 151 CROATIAN 003 ITALIAN 129 ORRI (ORING) 034 VIETNAMESE 098 CROW 011 JAPANESE 118 PAMPANGAN 114 WELSH 020 CZECH 139 KACHE (KAJE, JJU) 053 PANJABI (PUNJABI) 088 WINNEBAGO 041 DANISH 063 KANNADA (KANARESE) 131 PASHTO (PUSHTO) 016 YIDDISH 028 DUTCH/FLEMISH 066 KASHMIRI 009 PILIPINO (TAGALOG) 126 YOMBE 144 EFIK 119 KONKANI 082 PIMA 090 YORUBA 111 ESKIMO 008 KOREAN 004 POLISH 099 OTHER

Chicago Public Schools Office of Language and Cultural Education

STATE OF ILLINOIS DEPARTMENT OF HUMAN SERVICES

CERTIFICATE OF CHILD HEALTH EXAMINATION Please Print

Student’s Name Last First Middle

Birth Date

Month/Day/ Year

Sex School Grade Level /ID#

Address Street City ZIP code

Parent/ Telephone # Guardian Home Work

IMMUNIZATIONS: To be completed by health care provider. Note the mo/da/yr for every dose administered. The day and month is required if you cannot determine if the vaccine was given after the minimum interval or age. If a specific vaccine is medically contraindicated, a separate written statement must be attached explaining the medical reason for the contraindication.

VACCINE/DOSE 1 MO DA YR

2 MO DA YR

3 MO DA YR

4 MO DA YR

5 MO DA YR

6 MO DA YR

Diphtheria, Tetanus and Pertussis (DTP or DTaP)

Diphtheria and Tetanus (Pediatric DT or Td)

Inactivated Polio (IPV)

Oral Polio (OPV)

Haemophilus influenzae type b (Hib)

Hepatitis B (HB)

Varicella (Chickenpox)

Combined Measles, Mumps and Rubella (MMR)

Measles (Rubeola)

Rubella (3-day measles)

Mumps

Comments

¨PCV7 ¨PPV23 ¨PCV7 ¨PPV23 ¨PCV7 ¨PPV23 ¨PCV7 ¨PPV23 ¨PCV7 ¨PPV23 ¨PCV7 ¨PPV23 Pneumococcal (not required for school entry)

Check specific type (PCV7, PPV23)

Other (Specify hepatitis A, meningococcal, etc.)

Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above immunization history must sign below. Signature Title Date

Signature (If adding dates to the above immunization history section, put your initials by date(s) and sign here.) Title Date

Signature (If adding dates to the above immunization history section, put your initials by date(s) and sign here.) Title Date

ALTERNATIVE PROOF OF IMMUNITY 1. Clinical diagnosis is acceptable if verified by physician. *(All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence.)

*MEASLES (Rubeola) MO DA YR MUMPS MO DA YR VARICELLA MO DA YR Physician’s Signature 2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official.

Person signing below is verifying that the parent/guardian’s description of varicella disease history is indicative of past infection and is accepting such history as documentation of disease. Date of Disease Signature Title Date

3. Laboratory confirmation (check one) ¨̈ Measles ¨̈ Mumps ¨̈ Rubella ¨̈ Hepatitis B ¨̈ Varicella Lab Results Date MO DA YR (Attach copy of lab report, if available.)

VISION AND HEARING SCREENING DATA

Pre-school – annually beginning at age 3; School age – during school year at required grade levels

Date Age/Grade R L R L R L R L R L R L R L R L R L R L

Vision Hearing

Code: P = Pass F = Fail U = Unable to test R = Referred G/C = Glasses/ Contacts

Printed by Authority of the State of Illinois

(Complete Both Sides) IL444-4737 (R-01-05)

Student’s Name Birth Date Sex School Grade Level/ ID #

Last First Middle Month/Day/ Year HEALTH HISTORY TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER

ALLERGIES (Food, drug, insect, other) MEDICATION (List all prescribed or taken on a regular basis.)

Diagnosis of asthma? Child wakes during the night coughing

Yes No Yes No

Indicate Severity Loss of function of one of paired organs? (eye/ear/kidney/testicle) Yes No

Birth defects? Yes No

Developmental delay? Yes No

Hospitalizations? When? What for? Yes No

Blood disorders? Hemophilia, Sickle Cell, Other? Explain.

Yes No Surgery? (List all.)

When? What for? Yes No

Diabetes? Yes No Serious injury or illness? Yes No

Head injury/Concussion/Passed out? Yes No TB skin test positive (past/present)? Yes* No

Seizures? What are they like? Yes No TB disease (past or present)? Yes* No

*If yes, refer to local health department.

Heart problem/Shortness of breath? Yes No Tobacco use (type, frequency)? Yes No

Heart murmur/High blood pressure? Yes No Alcohol/Drug use? Yes No

Dizziness or chest pain with exercise?

Yes No Family history of sudden death before age 50? (Cause?) Yes No

Dental ¨Braces ¨Bridge ¨Plate Other Eye/Vision problems? _____ Glasses ¨ Contacts ¨ Last exam by eye doctor _______ Other concerns? (crossed eye, drooping lids, squinting, difficulty reading)

Other concerns? Ear/Hearing problems?

Yes No

Bone/Joint problem/injury/scoliosis? Yes No

Information may be shared with appropriate personnel for health and educational purposes. Parent/Guardian Signature Date

Entire section below to be completed by MD/DO/APN/PA (*INDICATES TESTING MANDATED FOR STATE LICENSED CHILD CARE FACILITIES) Yes No

PHYSICAL EXAMINATION REQUIREMENTS HEIGHT WEIGHT BMI B/P

DIABETES SCREENING BMI>> 85% age/sex Yes ¨ No ¨ And any two of the following: Family History Yes ¨ No ¨ Ethnic Minority Yes ¨ No ¨ Signs of Insulin Resistance (hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans) Yes ¨ No ¨ At Risk Yes ¨ No ¨

LEAD RISK QUESTIONNAI RE* Required for children age 6 months through 6 years enrolled in licensed or public school operated day care, preschool, nursery school and/or kindergarten. Blood Test Indicated? Yes ¨̈ No ¨̈ Blood Test Date Blood Test Result (Blood test required in Chicago and other high risk zip codes.)

TB SKIN TEST Recommended only for children in high -risk groups including children who are immunosuppressed due to HIV infection or other conditions, recent immigrants from high prevalence countries, or those exposed to adults in high -risk categories. See CDC guidelines. Date Read / / Result mm

LAB TESTS *INDICATES TESTING MANDATED FOR STATE LICENSED CHILD CARE FACILITIES

Date Results Date Results

Hemoglobin * or Hematocrit * Sickle Cell * (as indicated)

Urinalysis Other

SYSTEM REVIEW Normal Comments/Follow-up/Needs Normal Comments/Follow-up/Needs

Skin Endocrine

Ears Gastrointestinal

Genito-Urinary LMP Eyes Normal Yes¨ No¨ Objective screening Yes¨ No¨ Result______________ Amblyopia Yes¨ No¨ Referred to Opthalmologist/Optometrist Yes¨ No¨ Neurological

Nose Musculoskeletal

Throat Spinal examination

Mouth/Dental Nutritional status

Cardiovascular/HTN

Respiratory

Mental Health

NEEDS/MODIFICATIONS required in the school setting

DIETARY Needs/Restrictions

SPECIAL INSTRUCTIONS/DEVICES e.g. safety glasses, glass eye, chest protector for arrhythmia, pacemaker, prosthetic device, dental bridge, false teeth, athletic support/cup

MENTAL HEALTH/OTHER Is there anything else the school should know about this student? If you would like to discuss this student’s health with school or school health personnel, check title: ¨ Nurse ¨ Teacher ¨ Counselor ¨ Principal

EMERGENCY ACTION needed while at school due to child’s health condition (e.g., seizures, asthma, insect sting, food, peanut allergy, bleeding problem, diabetes, heart problem)? Yes ¨ No ¨ If yes, please describe.

On the basis of the examination on this day, I approve this child’s participation in (If No or Modified,please attach explanation.) PHYSICAL EDUCATION Yes ¨̈ No ¨̈ Modified ¨̈ INTERSCHOLASTIC SPORTS (for one year) Yes ¨̈ No ¨̈ Limited ¨̈

Physician/Advanced Practice Nurse/Physician Assistant performing examination Print Name Signature Date

Address

Phone

(Complete both sides)

    ENGLISH

Race and Ethnicity Survey

Student’s Name: School Name: Gender: School ID: Birth Date: INSTRUCTIONS: Please answer the questions below. Both questions must be answered. Part A asks about the student's ethnicity and Part B asks about the student's race. If you decline to respond to either question, the school district is required to provide the missing information by observer identification.

Part A. Is this student Hispanic/Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.) Choose only one.

□ No, not Hispanic/Latino

□ Yes, Hispanic/Latino

The question above is about ethnicity, not race. No matter which answer you selected, continue and respond to the question below by marking one or more boxes to indicate what you consider this student's race to be.

Part B. What is the student'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 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.)