DERRICK THOMAS ACADEMY 2012-2013 Derrick Thomas Academy FORM 1a

Student Name
FORM 1a
Grade for Fall 2012
__ PK4 __K __1 __2 __3 __4
__5 __ 6 __7 __8
__9 __ 10 __11
DERRICK THOMAS ACADEMY 2012-2013
Derrick Thomas Academy
The Derrick Thomas Academy is a tuition-free public charter school, serving students in grades PK4 -- 11. Parents, students, and
teachers will be expected to attend quarterly conferences in which they promise to work together for student success.
Student Information (please print)
Student’s Legal Name ___________________________________________________________________
Mailing Address_____________________________ City ____________ State_____ Zip ________________
Date of Birth _____/ _____/______
M/F
Ethnicity (Circle One): Hispanic/Latino
Social Security Number ______________________________
Not
/Latino
Race (Circle All That Apply):
Black/African American
American Indian/Alaskan Native
Asian
White
Native Hawaiian
Primary Parent/Guardian Information (please indicate address of residence)
Name #1
________________________________________________________________
Last
First
Mailing Address:
__________________________________________________________________
Work Place/City
__________________________________________________________________
Phone Numbers
___________________________________________________________________
Home
Work
Cell
Email Address____________________________________________________________________________
---------------------------------------------------------------------------------------------------------------------------------------------------
Name #2
_________________________________________________________________
Last
First
Mailing Address:
___________________________________________________________________
Work Place/City
___________________________________________________________________
Phone Numbers
___________________________________________________________________
Home
Business
Cell
For Office Use Only
Taken by:_________________
Derrick Thomas Academy
FORM 1b
Student Enrollment Form
Student Dismissal Information
To ensure the safety of all students, parents or guardians must provide the school with the following
information. The main office will keep a copy of this form. Your child will not be released to anyone other
than those who are authorized on this form. Everyone listed below may be asked to provide valid
picture identification when coming to pick up your child.
__My child has permission to walk home alone after school.
__My child rides the bus home. My child’s bus route is
.
__My child will be picked up after school. (List all persons whom you authorize to pick up your child.)
The list below includes the people that can pick up my child from school for an emergency or for
regular dismissal. I understand they are required to show picture identification when coming to pick
up my child.
Name
Phone
Relationship
Any Additional Arrangements: _____________________________________________________
________________________________________________________________________________
Are any brothers or sisters planning to apply to the Derrick Thomas Academy? __ Yes
__ No
Please list the names and grades and indicate whether they are applying or attending:
You must fill out a new application for each child applying.
Brother or Sister’s Name ________________________
Applying
Attending
Grade for 2012 ________
Brother or Sister’s Name ________________________
Applying
Attending
Grade for 2012 ________
Brother or Sister’s Name ________________________
Applying
Attending
Grade for 2012 ________
How did you hear about us?
Door to Door
Referred by: ______________________________________________________________________________________________
Information Verification: The information provided on this form is true and accurate. I understand that
falsification of any information contained on this form or the use of any fraudulent means to achieve an
enrollment or assignment shall be cause for revocation of the student’s enrollment at DTA.
Parent/Guardian Signature ________________________________________ Date ____ / ____ /_________
For Office Use Only
Taken by:_________________
FORM 2a
Derrick Thomas Academy
LEGAL DOCUMENTATION
To ensure that your child/ children’s visitor and / or dismissal process is handled in the safest manner, the
following information is needed at the time of enrollment.
1. Complete all information on the Student Dismissal Information (Form 8).
2. A copy of any paper work that shows parental/ guardianship of you child/ children
A.
B.
C.
D.
Adoption papers
Foster care
Order Of Protection
Any other legal documents signed by a judge.
Please check the appropriate box below.

No, I do not have any legal documentation on my child that school needs to be aware of (other than birth
certificate).

Yes I do have legal documentation that Derrick Thomas Academy needs and I will provide the school with
a copy of the documentation.

Yes I do have legal documentation that Derrick Thomas Academy needs but I will not be providing a copy
of the necessary documentation.
It is the parent/guardians responsibility to keep Derrick Thomas Academy updated on any legal custody
changes, temporary or permanent. By signing your name below you are acknowledging that you understand
the above information.
_______________________ ___________________
Signature
Relationship
___________
Date
Social Security Number Usage Disclosure
Derrick Thomas Academy uses Social Security Numbers (SSN) to verify student identities when exchanging
records with other educational institutions, including the Missouri Department of Elementary and Secondary
Education (DESE). DESE uses the SSN along with other information to verify a student’s identity when
assigning the student an ID number in the Missouri Student Information System (MOSIS), which is used to track
student attendance and absence hours and other enrollment information. The SSN will be kept strictly
confidential; it will only be available to a limited number of enrollment officials in the school and limited
members of the MOSIS staff at DESE. Parental disclosure of a student’s SSN is voluntary and will not prevent
the student from being enrolled at Derrick Thomas Academy, although it may affect the accuracy of data
collection and reporting as required by No Child Left Behind and other federal and state regulations. This
disclosure in provided in accordance with section 7 (a) of 5 U.S.C. § 552a, The Privacy Act Of 1974, as
amended.
FORM 2b
Derrick Thomas Academy
Student Service Intake Form
Derrick Thomas Academy is fully committed to providing quality education to all of our students, including
those with special needs. We need your help, so please complete this page with care.
SECTION 1
Check Yes or No as applicable:
Yes
No
Was your child involved with Early Intervention services (birth to 3)?
Has your child ever been screened for special education?
If yes, what school/facility that did testing: ______________________________________________________
Did your child qualify for special education services?
Does she/he currently qualify? If yes, please complete section 2 of this form.
Does your child take medication for any medical reason (ADHD, Diabetes, etc.)?
If yes, what medication does she/he take? _____________________________________________________
Does your child wear glasses?
Does your child use a hearing aid?
SECTION 2 – FILL OUT ONLY IF YOUR CHILD HAS A CURRENT IEP OR 504 PLAN
What type of plan does your child have? IEP ________________ 504 Plan ___________________
If your child has either of these, you must submit a copy to DTA IMMEDIATELY.
Diagnosis (check all that apply)
Learning Disability
in _______Reading _________ Math _______ Written Expression
Mental Retardation
Emotional Disturbance/Behavior
Disorder
Hearing Impairment
Traumatic Brain Injury
Speech/Language Impairment
Other Health Impaired
Visual Impairment
Orthopedic (Physical) Impairment
Young Child with a
Developmental Delay
Other ________________________________________________________________________________________________
Please indicate which of the following services your child receives through that IEP or 504 Plan.
(Check all that apply.)
Speech and Language
Occupational Therapy
Resource Room
Self-Contained Classroom
Inclusion Services
Counseling
Physical Therapy
Visually Impaired
Adaptive Physical Education
Deaf or Hard of Hearing
Other__________________________________________________________
Because we are legally obligated to provide your child with all services on his/her IEP or 504 Plan, it
is extremely important that you let us know if your child has an IEP or 504 Plan. Your signature
indicates that all information on this form is correct. Please sign below to indicate that you
understand this and have provided full and accurate information.
__________________________________________________
Parent Signature
_______________________
Date
For Office Use Only
Taken by:_________________
FORM 3a
Derrick Thomas Academy
Home Language Survey & Residency Information
Student Name ________________________________________
Is a language other than English used at home?
___Yes
___No
What was the first language your child learned to speak?
___English ___Spanish ___ Other ________________________
What language(s) does your child speak most often at home?
___English ___Spanish ___ Other ________________________
What language(s) is spoken most often in your home.
___English ___Spanish ___ Other ________________________
How long has your child been in the United States of America in the public school system?
____Born in USA ____4 or more years ___0-3 years
Are you currently residing in a hotel, motel, car, or at a campsite because your home has been damaged or
because of economic reasons?
___Yes
___No
Are you sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason?
___Yes
___No
Explanation:________________________________________________________
Are you currently residing in a shelter?
___Yes
___No
Are you currently living in a temporary housing arrangement due to economic hardship?
___Yes
___No
Have you moved within the past 3 years to seek or obtain work?
___Yes
___No
Does the work fall into any of the following categories?
___Yes
___No
If “yes”, mark which ones:
o Planting or harvesting crops
o Feeding poultry, gathering eggs, working in a hatchery
o Processing meat, poultry, fruit or vegetables, dairy products
o Commercial fishing or working on a fish farm
______________________
______________
Parent/Guardian Signature
Date
For Office Use Only
Taken by:_________________
FORM 3b
Derrick Thomas Academy
Medical and Emergency Information
Please list any allergies to environment, food, or medication and the reaction to each:
Allergy
Reaction
Please list your child’s health history, including illnesses, diseases, or surgeries and year of each
where applicable:
Illness, Disease, Surgery
Year
Illness, Disease, Surgery
Year
Please list your child’s current medication(s):
Medication
Dose Amount Form
# of Times
per Day
Prescribing
Doctor
Please state why your child is taking this medication (the doctor’s diagnosis):
*IF YOUR CHILD IS ON MEDICATION PRESCIRBED BY A MEDICAL DOCTOR THAT REQUIRES HIM/HER TO TAKE
IT DURING THE SCHOOL DAY, THE MEDICATION MUST BE BROUGHT TO THE SCHOOL NURSE IN ITS
ORIGINAL CONTAINER WITH THE PERSCRPTION LABEL ON IT . NEITHER THE NURSE NOR THE DTA STAFF
WILL STOCK OR GIVE OUT ANY OVER THE COUNTER MEDICATION.
Medical and Emergency Information
I give permission to Derrick Thomas Academy to seek medical treatment for my child in the event of a
medical emergency. I will be responsible for the cost of any emergency medical care provided to my
child.
Doctor
_________________________________ Dr.’s Phone ______________________
Preferred Hospital ______________________________________________________________
Parent/Guardian Signature:__________________________________________________
Insurance Carrier:_____________________________ Type of Insurance:_____________________
Insurance Policy #:_____________________ or *____ My child is not covered by medical insurance.
For Office Use Only
Taken by:_________________
FORM 4a
Derrick Thomas Academy
Media Release Form
Print, broadcast, and Internet media sometimes cover events at the school. Only students with a signed media
release form can participate in these events. In addition, photographs are sometimes taken which may be
used in such venues, parent newsletter, or on the school website.
I, (parent name) _______________________________, grant permission as the legal parent/guardian of
(student name) _____________________, to Derrick Thomas Academy to use photographs and or video
footage of my child in marketing and or promotional materials and for release to the media.
I, (parent name)______________________________do not wish for (student name)____________________
to appear in any forms of media.
Parent/Guardian Name _____________________________________________________
Parent/Guardian Signature __________________________________________________
Date: _____________
Library Agreement
1. Each student may select one book to take home for one week.
2. Students must return their book before they can check out a new one.
3. Students will be charged a fee of $.20 per day for late books.
Parent/ Guardian Help
1. Help your child find a safe and consistent place to read; away from crayons, infants, food and other
things that may damage the book.
2. Encourage and help your child return his/her book on time.
3. Help your child learn to hold a book carefully and turn pages with clean hands.
4. Encourage your child to read to you.
5. Invite your child to retell the story to you.
6. If you child damages or loses his/her book you will be charged the cost of the book. If the barcode or
spine label is missing, you will be charged a $3.00 fee.
This form must be completed before your child may check out a book.
----------------------------------------------------------------------------------------------------------------------------------I AGREE TO FOLLOW THE DERRICK THOMAS ACADEMY’S LIBRARY RULES.
_______________________________
Student’s Name
____________________________________
Student’s Signature
_________________________________
Parent/Guardian’s Name
____________________________________
Parent/Guardian’s Signature
_______________________________
Grade
____________________________________
Date
For Office Use Only
Taken by:_________________
FORM 4b
Derrick Thomas Academy
Request for Records
Please complete this form by:
1)
Listing your child’s current school and address
2)
Filling in your child’s full name, grade and ID number
3)
Signing on the space provided at the bottom of this page
Your signature grants the sending school permission to forward your child’s school records to
Derrick Thomas Academy.
Child’s Former School ________________________________________________________
Former School Address
_____________________________________________________
Street
Apt. #
_____________________________________________________
City
State
Zip Code
Former School Telephone Number ________________________________________________
Former School Fax Number_______________________________________________________
To: School Records Clerk
From: Derrick Thomas Academy
Student Name:
Date of Birth:
Grade:
ID # (if available):
This student has enrolled in the Derrick Thomas Academy for the 2012-2013 school year. Please
include the contents of the student’s cumulative records: Health Records, Report Cards, Behavior
Record, Special Education Reports ( if any), Primary Language and Standardized Test Scores.
_____________________________________________________
Parent/Guardian’s Signature
_______________
Date
Please forward Educational Records To:
Enrollment and Retention Specialist
Derrick Thomas Academy
201 East Armour Boulevard
Kansas City, Missouri 64111
(816) 531-7144 or Fax (816) 753-8856
Please forward Special Education Records To:
Special Education Coordinator
Derrick Thomas Academy
201 East Armour Boulevard
Kansas City, Missouri 64111
(816) 531-7144 or Fax (816) 753-8856
Parental permission is no longer required when records are requested by authorized personnel (Family
Educational rights and Privacy Acts, Final Rule on Educational Records, Federal Register, and June
17, 1976. Vol. 41 No 118, page 24673).
Thank you in advance for your prompt attention to this matter.
For Office Use Only
Taken by:_________________
FORM 5a
Derrick Thomas Academy
School Visitation and Volunteers Guidelines &
Volunteer Commitment
Volunteers are an integral part of our school. We recognize the time, expertise, support and
assistance they give. Parents and other community citizens are encouraged to volunteer at Derrick
Thomas Academy. Parents are required to volunteer 10 hours during the school year.
Volunteer Procedures
1. Volunteers must report to the main office upon entering the building.
2. Volunteers must sign in and out on the Volunteer Log sheet.
3. A volunteer badge must be worn at all times.
4. CONFIDENTIALITY must be kept. Please never discuss a student’s grades or progress with anyone. Our
children have a right to privacy.
5. Discipline should be handled by the staff and administrators. Please report any behavior concerns with
staff and administrators.
6. Please dress comfortably. No shorts, hats, tanks, mini-skirts and other inappropriate clothing are allowed.
Volunteer Expectations
1. Remember you are a role model for our students and should conduct yourself accordingly.
2. Work appropriately and respectfully with all students and staff.
3. Be respectful to our youth and their family’s privacy.
4. Don’t ignore behavior or actions that you feel are wrong or disrespectful.
5. Maintain a positive and helpful attitude.
6. If you signed up to volunteer and cannot make it, please call (816) 531-7144 to let the office know.
We hope you will find your volunteering experience a rewarding one. You have the opportunity to improve a
child’s learning experience and to encourage that child toward a bright future. We are glad you have chosen to
be a volunteer at Derrick Thomas Academy and hope you will not hesitate to let us know how we can improve
the experience for you.
I have read and understand the guidelines above.
_____________________________________________________
Parent/Guardian’s Signature
_______________
Date
Yes, I would like to volunteer!
Parent/Guardian Name_________________________Child’s Name: _____________________________
Telephone: ___________________________________________________________________________
I am available the following days:____________________________________________________________
I am available at the following times: _________________________________________________________
 Tardy Passes (8:00 – 10:00)
 Cafeteria Assistance (Lunch Hours 10:30 AM – 1:30 PM)
 Reading Program
 Special Events and Celebrations
 Library Assistant
 Room Parent/Guardian
 DTA Parent Advisory Council
 Classroom Helper
 Field Trips
 Coach for one of the athletic teams: preference on the sport _______________________________
 Other___________________________________________
Thank you for sharing your time and talents with our students!
For Office Use Only
Taken by:_________________
FORM 5b
Derrick Thomas Academy
Parental/Guardian Contract for Enrollment
Derrick Thomas Academy is well on its way to becoming one of the truly remarkable school programs in
our nation, our families agree that the following program components are necessary to build the kind of
learning environment of which everyone can be proud of.
Derrick Thomas Academy Parents/Guardians agrees: (Please initial next to each item.)

To support the school’s efforts to remove violent/inappropriate behavior from the school.

To support the school by ensuring that my child complies with all policies outlined in the Family
Handbook and School Code of Conduct.
____

To attend all of the Parent/Teacher conferences.
____

To attend a minimum of three PAC meeting throughout the 2012 – 2013 school year.
____

To volunteer at the school a minimum to ten hours during the school year.
____

To purchase and maintain the necessary school dress code items for each child, and to ensure
that my child is dressed in compliance with the dress code policy every day that they are in
attendance at DTA. (All details of the Schools Dress Code Policy can be found in the Family
Handbook. If I do not have a copy of this information it is my responsibly to obtain it.)
____

To send my child to school every day at scheduled start time; unless ill.

I will ensure that my child is not dropped off for school prior to scheduled time and I will ensure
that my child is picked up from school by scheduled time daily.
____

To send my child to school until the last scheduled school day.
____
____
____
I agree to support ___________________________________by following the Program
(Student’s Name)
Expectations as outlined in the above Parental/Guardian contract.
_____________________________________________
Parent/Guardian Signature
________________________
Date
For Office Use Only
Taken by:_________________
FORM 6a
Derrick Thomas Academy
Acceptable Use Policy for The Common and Online/Internet Services
Student Name ____________________________________________________________________
(Please Print)
(Last)
(First)
(Middle Initial)
As a student at the Derrick Thomas Academy, I agree to comply with the following computer
guidelines:
1. I will treat all computer equipment with care and will leave it in good working condition when I
am finished. I will BE SAFE, RESPONSIBLE, and KIND to the computers when I am using
them.
2. I understand that the school software cannot be copied by me to use on any other computer
because this would violate copyright law.
3. I will not bring in any of my own software to use on the school computers because this would
violate copyright law.
4. I will not share my passwords for the school computer or The Common (email system) with
anyone except my parent or guardian and my homeroom teacher.
5. I will take total responsibility for any messages that I send on The Common and I will not insult,
threaten other people, or use profanity.
6. I will not share my phone number or home address over The Common because it is not safe to
share this information over the computer.
7. I understand that all other school rules apply to using The Common.
8. I understand that if I violate any of the above rules, I will lose my computer and/or Common
Privileges.
(Student Signature)
(Date)
As the parent of (student name) ________________________________________ I understand the
school policy regarding computer usage and will do the best I can to model your guidelines to my
child.
(Parent Signature)
(Date)
For Office Use Only
Taken by:_________________