2013/2014 School Year Enrollment Forms Fax Cover Sheet

Washington Virtual Academies
Th
2601 S 35 St, Suite 100
Tacoma, WA 98409
Ph: 866-467-6187
Fx: 253-295-4798
2013/2014 School Year
Enrollment Forms Fax Cover Sheet
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): 1-253-295-4798
Scan and Email: [email protected]
Mail: Washington Virtual Academies
2601 S 35th Street, Suite 100
**All Students 18 Years and Older Must Sign ALL Enrollment Paperwork**
Tacoma, WA 98409
Student Name: ______________________________________________________________________________________________________
Parent/Guardian Name: _______________________________________________________________________________________________
Number of pages including cover sheet: ___________ Date: ___________
New Student Enrollment Forms Checklist
(Please check each form you are including in your fax)
Birth Certificate (if enrolling in Kindergarten)
Certificate of Immunizations-Be sure to sign this form in the top Right Corner or the form will be Rejected, (please make sure Immunizations are transcribed
onto the WA State form provided, parents are required to send this in at the time of enrollment)
Proof of Residence (utility bill, if living with family, friends, or any other circumstances please include a letter stating you and your family are residing at
their residence and a copy of their utility bill or signed Lease/Rental Agreement)
13/14 Inter District/Choice Release Registration Form
Release of Student Records (this form is to be sent directly to WAVA and not turned into your resident school/school district, WAVA will send upon
approval)
9Th Grade students most recent Report Card or Progress Report
10th-12Th Grade students Unofficial or Official transcript
If your student has a 504 Plan, please submit a copy
If your student has an IEP, WAVA will request a copy
If you have indicated you have a Parenting Plan or Restraining order, Please submit a copy
Re-Enrolling Student Enrollment Forms Checklist
(Please check each form you are including in your fax)
Proof of Residence if you have moved
If your student is entering the 6Th grade please provide the date for the Tdap Booster Immunization (this is required to enter the 6 th grade)
13/14 Inter District/Choice Release Registration Form
If you have indicated you have a Parenting Plan or Restraining order, Please submit a copy
2013/2014 New Student Registration Form
WAVA Monroe WAVA Omak
Student Name First
Grades K-8
Middle
Grades 9-12
Phone: 1-866-467-6187
Legal Last Name (as appears on Birth Certificate)
Last Name also known as:
Birthdate
Washington Virtual Academies
Enrollment Processing Center
2601 South 35th Street, Ste 100
Tacoma, WA 98409
Fax: 1-253-295-4798
www.wava.org
Grade Entering
Phone Number
Statement of Understanding
DISCIPLINE INFORMATION (please check your answers)
Has your child ever been suspended? YES NO If Yes, Why:
____________________________________________________________________________________
Has your child ever been Expelled? YES NO If Yes, Why:
____________________________________________________________________________________
Is your student currently under a suspension, expulsion, or Becca Bill/Truancy Petition? YES NO If
yes, Name of School: __________________________________________________________________
CUSTODY INFORMATION (please check your answers)
Who is the primary custodial parent? ____________________________________________________________
Is there a joint custody or parenting plan in effect? YES NO
Is there a restraining order in effect? YES NO
Restraining order is against? Mother Father Other: _________________________________________
Begin Date: ______________________ Exp Date: ________________
*Please note if there is a restraining order or parenting plan in affect you will need to send in a copy prior
to students enrollment approval.*
If Suspended or Expelled, Why: _________________________________________________________
In accordance with the Alternative Learning Experience Implementation Standards, reference WAC 392-121-182 (3)(e), prior to enrollment parent(s) or guardians shall be provided with, and sign, documentation attesting to
the understanding of the difference between home-based instruction an enrollment in an alternative learning experience (ALE).
Home-Based Instruction (Home School not using WAVA Program
Alternative Learning Experience-Washington Virtual Academies
 Is provided by the parent or guardian as authorized under RCW 28A.200 and 28A.225.010.
 Is authorized under WAC 392-121-182.
 Students are not enrolled in Public Education.
 Students are enrolled in public education either full time or part time.
 Students are not subject to the rules and regulations governing public schools, including  Students are subject to the rules and regulations governing public school students including course, graduation, and
course, graduation, and assessment requirements.
assessment requirements for all portions of the ALE.
 The public school is under no obligation to provide instruction or instructional materials, or  Learning experiences are:
otherwise supervise the student’s education.
 Supervised, monitored, assessed, and evaluated by certified staff.
 Provided via a written student learning plan.
 Provided in whole, or part outside the regular classroom.
Part –time Enrollment of Home-Based Instruction Students
Home-based instruction students may enroll in public school programs, including ALE programs, on a part-time basis and retain their home-based instruction status. In the case of part-time enrollment in ALE, the student
will need to comply with the requirements of the ALE written student learning plan, but not be required to participate in state assessments or meet state graduation requirements.
*Please note Part-Time Enrollment of Home-Based Instruction is aside from Washington Virtual Academies as we are an ALE Program and a Public School.*
I have read the descriptions of home-based instruction and alternative learning experiences provided and understand the difference between home-based instruction and the alternative learning experience
program in which my child is enrolling.
Parent/Guardian/Student Signature: _______________________________________________________________________________________________________________________
Date_____________________
**All Students 18 Years and Older Must Sign ALL Enrollment Paperwork**
Ethnicity and Race Data Collection
Question 1 Is your child of Hispanic or Latino origin? (Check all that apply)
Mexican/Mexican American/Chicano Not Hispanic/Latino
Latin American
Puerto Rican
Question 2 What race(s) do you consider your child? (Check all that apply)
Cuban
Other/Hispanic/Latino
Central American
Spaniard
Dominican
South America
African American/Black
Indonesian
Taiwanese
Guamanian or Chamorro
Alaska Native
Makah
Pakistani
Lummi
White
Japanese
Thai
Mariana Islander
Chehalis
Muckleshoot
Squaxin Island
Yakama
Asian Indian
Korean
Vietnamese
Melanesian
Nooksack
Nisqually
HOH
Chinese
Laotian
Other Asian
Samoan
Native Hawaiian
Spokane
Stillaguamish
Sohal Water
Snoqualmie
Sauk-Suiattle
Tongan
Cowlitz
Puyallup
Jamestown
Filipino
Malaysian
Colville
Samish
Quinalut
Port Gamble Klallam
Suquamish
Hmong
Singaporean
Fijian
Kalispel
Lower Elwha
Quileute
Tulalip
Legal Parent/Guardian Signature _______________________________________________________________________________________________
**All Students 18 Years and Older Must Sign ALL Enrollment Paperwork**
Date ___________
2013/2014 Inter‐District/Choice Release Registration Form Washington Virtual Academies
Enrollment Processing Center
2601 South 35th Street, Ste 100
Tacoma, WA 98409
WAVA Monroe WAVA Omak
Grades K-8
Grades 9-12
Phone: 1‐866‐467‐6187 Fax: 1‐253-295-4798 www.wava.org
Student Name First
Middle
Legal Last Name (as appears on Birth Certificate)
Last Name also known as:
Birthdate
Grade Entering
Phone Number
______________________________________________________________________________________
Name of Resident School District: __________________________________________________________________ Physical Street Address
Name of Current School: _________________________________________________________________________
City
Zip Code
State the reason(s) why the transfer is requested: _________________________________________________________________________________________________________________________________________________
Is your student currently enrolled in a special program:
Is the IEP Current?
Yes
Yes
No IEP Date: __________________
No
If yes, please check all that apply. TITLE 1/Chapter 1 IEP/Special Education GIFTED ESL/ELL/ESL Services/ELL Plan 504
Evaluation Date: __________________ Is the 504 Current?
Yes
No Date: __________________
What is the primary language in the home? ____________________________ Is your child's first language a language other than English? YES NO If yes, what language? ______________________
My student is Special Education and will be receiving all Special Education Services and associated courses at___________________________________________________, in the______________________________________
School District.
1.)
How will you be enrolling your student with Washington Virtual Academies? (Choose ONE of the options below)
My student will attend Washington Virtual Academies Full Time 1.0 FTE
Kindergarten
Grades 1-8
Math/Language Arts
Math
Language Arts
Science
Science
Grades 9-12 (please fill in courses)
History/Art
PE
2.)
My student will attend Washington Virtual Academies Part Time and claim Part Time Home School status. By choosing this option you must sign the Intent to Provide Home School Instruction below.
WAVA Courses
Total FTE:
Home School Courses (these courses will be independently instructed)
________________
Total FTE:
________________
Declaration of Intent to Provide Home School Instruction Note: Washington Virtual Academies is a Public School
A Parent who intends to cause his/her child or children to receive home school instruction in lieu of attendance or enrollment in a public school, approved private school, or an extension program of an approved private school must file an annual declaration of intent to
do so in the format prescribed below:
I do hereby declare that I am the parent, guardian, or legal custodian of the child listed below; that said child is between 5 and 17 and as such are subject to the requirements found in chapter 28A.225 RCW Compulsory Attendance; I intend to cause said child to receive
home school instruction as specified in RCW 28A.225.010(4); and if a certificated person will be supervising the instruction, I have indicated this by checking the appropriate space.
X
Parent/Guardian/Student Printed Name & Signature
3.)
Date
My student will attend both Washington Virtual Academies and (name of school) ___________________________________________, in the________________________________________ School District.
The Washington Virtual Academies (WAVA) is an Alternative Learning Experience (ALE). The above named student is enrolled in your district and would like to exercise his/her option to take some courses through WAVA RCW 28A.225.220). According to WAC 392-121-188,
school districts have the authority to enter into Inter-district cooperative agrees with other school districts under RCW 28A.225.250. Please complete the form below to ensure our district under RCW 28A.225.250. Any student enrolled in WAVA with a .60 FTE or higher, WAVA will
be responsible for the student(s) testing. Any student attending the RSD with a FTE of .60 or higher, the RSD will be responsible for the student(s) testing.
Resident School Courses
Total FTE:
________________
FTE
WAVA/Omak HS Courses (.20 FTE per WAVA Course)
Total FTE:
________________
FTE
WAVA K8 Courses (.25 per WAVA Course)
Total FTE:
FTE
________________
Parent/Guardian Name & Signature_______________________________________________________________________________________________________________________Date:_______________
Enrollment Acceptance/Denial Signature
Resident District Signature ___________________________________________________________________________________________
Non-Resident District Signature________________________________________________________________________________________
Approved
Approved
Denied FTE:_________ Date: ____________
Denied FTE:_________ Date: ___________
Washington Virtual Academies Enrollment Processing Center 2601 South 35th Street, Ste 100 Tacoma, WA 98409 Ph. 1.866.467.6187 Fx. 1. 253-295-4798 www.k12.com/wava 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). Please do not send any records unless this form has been sent to you directly by a Washington Virtual Academies school official. Student Information Student’s Full Name: _____________________________________________________________________________________________________________________ First Middle Legal Last Also known as: Student’s Date of Birth: ________________________________ Home Phone: ____________________________ Student’s Legal Address: __________________________________________________________________________________________________________________ Street Apt # _______________________________________________________________________________________________________________________________________ City County State Zip Code Homeschooled or Never Previously Enrolled in School (fill out only if applicable) Check Below if Applicable: □ Student was always previously homeschooled □ Student is enrolling in Kindergarten □ Has your student ever attended a public school, private school, home school program, or any other accreditated program during his/her education time period? Yes __ No___ If yes, please complete below portion. Prior School Information Current School of Attendance: ____________________________________________________________________________________________________ School Address: _________________________________________________________________________________________________________________________ Street _______________________________________________________________________________________________________________________________________ City County State Zip Code Attended from: _____________________________ School Phone: ____________________________ School Fax: __________________________ Previous School of Attendance (if differs from above):_________________________________________________________________________________ School Address: _________________________________________________________________________________________________________________________ Street _______________________________________________________________________________________________________________________________________ City County State Zip Code Attended from: _____________________________ School Phone: ____________________________ School Fax: __________________________ Recognizing this legal requirement, I hereby verify that the student named above physically resides within Washington State and all of the above provided information is correct. Print name of Parent/Guardian/Student : ____________________________Parent/Guardian/Student Signature: ________________________Date:____________ **All Students 18 Years and Older Must Sign ALL Enrollment Paperwork** SCHOOL OFFICIALS ONLY: Send Records to: Washington Virtual Academies Official Student Records 2601 South 35th Street, Ste 100 Tacoma, WA 98409 Office Use Only:
Certificate of Immunization Status (CIS)
DOH 348-013
Reviewed by:
Date:
Signed Cert. of Exemption on file? 0 Yes 0 No
January 2010
Please print. See back for instructions on how to fill out this form or get
it printed from the Immunization Registry.
First Name:
Middle Initial:
Birthdate (mm/dd/yyyy): Sex:
I certify that the information provided on
Child’s Last Name:
this form is correct and verifiable.
Symbols below:
Vaccine
+ Required for School and Child Care/Preschool
• Required for Child Care/Preschool Only
Dose
Date
Month
Day
Vaccine
Year
+ Hepatitis B (Hep B)
1
2
3
Parent/Guardian Name (please print):
Parent/Guardian Signature Required
Dose
Month
Date
Day
Year
+ Polio (IPV, OPV)
option 1, 2, 3, OR 4 below – see, back #5.
1) 0
Chickenpox disease verified by printout from
CHILD Profile Immunization Registry
Must be marked by printout (not by hand) to be valid.
1
2
3
2) 0 Chickenpox disease verified by Health
Care Provider (HCP)
If you choose this box, mark 2A OR 2B below.
2A)
0 Signed note from HCP attached OR
2B)
0 HCP signed here and print name below:
4
or Hep B - 2 dose alternate schedule for teens
1
2
Rotavirus (RV1, RV5)
1
2
3
+ Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT)
1
2
3
4
5
+ Tetanus, Diphtheria, Pertussis (Tdap, Td)
1
2
• Haemophilus influenzae type b (Hib)
1
2
3
4
• Pneumococcal (PCV, PPSV)
1
2
3
4
Date
If the child named on this CIS had chickenpox disease (and
not the vaccine), disease history must be verified. Mark
Influenza (flu, most recent)
Licensed health care provider (HCP) Signature
Date
(MD, DO, ND, PA, ARNP)
+ Measles, Mumps, Rubella (MMR)
HCP Printed Name:
1
3) 0 Chickenpox disease verified by school staff
from CHILD Profile Immunization Registry
If you choose this box, staff must initial that parent or
guardian approves:
(initial)
(date)
2
+ Varicella (chickenpox) or verify disease 1-4 
1
2
4) 0 Chickenpox disease verified by parent*
If you choose this box, fill in the date or child’s age when
he or she had the disease:
Age/Date of disease:
*Can ONLY verify for some grades, see back #5 (4).
Hepatitis A (Hep A)
If the child can show immunity by blood test (titer) and
hasn’t had the vaccine, ask your HCP to fill in this box.
1
2
Documentation of Disease Immunity
Meningococcal (MCV, MPSV)
I certify that the child named on this CIS has laboratory
evidence of immunity (titer) to the diseases marked.
Signed lab report(s) MUST also be attached.
1
Human Papillomavirus (HPV)
1
2
3
Office Use Only: Immunization information updated
and verified with parent/guardian permission:
0
0
0
0
0
Diphtheria
Hepatitis A
Hepatitis B
Hib
Measles
0
0
0
0
0
Date
Printed Staff Name
Date
0
Other:
Licensed health care provider (HCP) Signature
(MD, DO, ND, PA, ARNP)
Printed Staff Name
Mumps
Polio
Rubella
Tetanus
Varicella
HCP Printed Name:
Date
Instructions for completing the Certificate of Immunization Status (CIS): printing it from the Immunization Registry or filling it in by hand.
#1 To print with info filled in: First, ask if your health care provider’s office puts vaccination history into the CHILD Profile Immunization Registry (Washington’s
statewide database). If they do, ask them to print the CIS from CHILD Profile and your child’s information will fill in automatically. Be sure to review all the information, sign
and date the CIS in the upper right hand box, and return it to school or child care. If your provider’s office does
not use CHILD Profile, ask for a copy of your child’s vaccine record so you can fill it in by hand using steps #2-7 (below):
EXAMPLE
#2 To fill in by hand: Print your child’s name, birthdate, sex, and your own name in the top box.
#3 Write each vaccine your child received under the correct disease. Write the vaccine type under the “Vaccine”
column and the date each dose was received in the “Month,” “Day,” and “Year” columns (as mm/dd/yyyy). For
example, if DTaP was received Jan 12, March 20, June 1, ’11, fill in as shown here 
#4 If your child receives a combination vaccine (one shot that protects against several diseases), use the
Reference Guide below to record each vaccine correctly. For example, record Pediarix under Diphtheria, Tetanus,
Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV.
Vaccine
Date
Dose
Month
Day
Year
+ Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT)
DTaP
01
12
2011
1
DTaP
03
20
2011
2
DTaP
06
01
2011
3
#5 If your child has had chickenpox (varicella) disease and not the vaccine, use only one of these four options to record this on the CIS:
1) 0 If your child’s CIS is printed directly from the CHILD Profile Immunization Registry (by your health care provider or school system), and disease verification is
found, box 1 is automatically marked. To be valid, this box must be marked by the Immunization Registry printout (not by hand).
2) 0 If your health care provider (HCP) can verify that your child has had chickenpox, mark box 2. Then mark either 2A to attach a signed note from your
HCP, or 2B if your HCP signs and dates in the space provided. Be sure your HCP’s full name is also printed.
3) 0 If school staff access the CHILD Profile Immunization Registry and see verification that your child has had chickenpox, they will mark box 3. Then,
they must initial and date that they got parent or guardian approval to mark this box (i.e. make this change) to the CIS.
4) 0 If your child started kindergarten in the 2008-2009 school year or later, you CANNOT use this box. If your child started kindergarten before the 08-09
school year, mark this box if you know he or she has had chickenpox. If you mark box 4, you must also write the approximate age or date your child had chickenpox.
To find out which grades require chickenpox vaccine (or history), visit: http://www.doh.wa.gov/cfh/immunize/schools/vaccine.htm
#6 Documentation of Disease Immunity: If your child can show immunity by blood test (titer) and has not had the vaccine, have your health care provider
(HCP) fill in this box. Ask your HCP to mark the disease(s), sign, date, print his or her name in the space provided, and attach signed lab reports.
#7 Be sure to sign and date the CIS in the upper right hand box, and return to school or child care.
#8 If a school or child care makes a change to your CIS, staff will print their name in the middle bottom box and date to show that you gave approval.
Vaccine Trade Names in alphabetical order
Trade Name
ActHIB
Adacel
Afluria
Boostrix
Cervarix
Comvax (Cmvx)
Daptacel
Decavac
Vaccine
Hib
Tdap
Flu (TIV)
Tdap
HPV2
Hep B + Hib
DTaP
Td
Vaccine
Trade Name
Vaccine
Trade Name
Vaccine
Trade Name
Vaccine
Engerix-B
Fluarix
FluLaval
FluMist
Fluvirin
Fluzone
Gardasil
Havrix
Hep B
Flu (TIV)
Flu (TIV)
Flu (LAIV)
Flu (TIV)
Flu (TIV)
HPV4
Hep A
Ipol
Infanrix
Kinrix (Knrx)
Menactra
Menomune
Pediarix (Pdrx)
PedvaxHIB
Pentacel (Pntcl)
IPV
DTaP
DTaP + IPV
MCV or MCV4
MPSV or MPSV4
DTaP + Hep B + IPV
Hib
DTaP + Hib + IPV
Pentavalente
Pneumovax
Prevnar
ProQuad (PrQd)
Quadracel (Qdrcl)
Recombivax HB
Rotarix
RotaTeq
DTaP + Hep B + Hib
PPSV or PPV23
PCV or PCV7 or PCV13
MMR + Varicella
DTaP + IPV
Hep B
Rotavirus (RV1)
Rotavirus (RV5)
TriHIBit
Tripedia
Twinrix (Twnrx)
Vaqta
Varivax
DTaP + Hib
DTaP
Hep A + Hep B
Hep A
Varicella
Vaccine Abbreviations in alphabetical order
Abbreviations
Full Vaccine Name
DT
Diphtheria, Tetanus
DTaP
DTP
(For updated lists, visit http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/us-vaccines-508.pdf)
Trade
Name
Diphtheria, Tetanus,
acellular Pertussis
Diphtheria, Tetanus,
Pertussis
Abbreviations
Hep A (HAV)
Hep B (HBV)
Hib
HPV
Flu
(TIV or LAIV)
Influenza
IPV
HBIG
Hepatitis B Immune
Globulin
MCV or MCV4
(For updated lists, visit http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/us-vaccines-508.pdf)
Full Vaccine Name
Hepatitis A
Hepatitis B
Haemophilus influenzae
type b
Abbreviations
Full Vaccine Name
Meningococcal
Polysaccharide Vaccine
Measles, Mumps, Rubella /
with Varicella
Abbreviations
Rota
(RV1 or RV5)
Td
Tetanus, Diphtheria
Human Papillomavirus
OPV
Oral Poliovirus Vccine
Tdap
Tetanus, Diphtheria, acellular
Pertussis
Inactivated Poliovirus
Vaccine
Meningococcal
Conjugate Vaccine
PCV or PCV7 or
PCV13
Pneumococcal Conjugate
Vaccine
Pneumococcal Polysaccharide
Vaccine
TIG
Tetanus immune globulin
VAR or VZV
Varicella
MPSV or MPSV4
MMR / MMRV
PPSV or PPV23
If you have a disability and need this document in another format, please call 1-800-525-0127 (TDD/TTY 1-800-833-6388).
Full Vaccine Name
Rotavirus
DOH 348-013 January 2010
CertificateofExemption
For School, Child Care and Preschool Immunization Requirements1
DIRECTIONS: All exemptions must have a licensed health care provider sign & date Box 1 (‘Provider Statement’).
Exception: Box 1 is not required for religious exemptions when Box 2 (‘Demonstration of Religious Membership’) is completed. All exemptions must also have a
parent/guardian sign & date Box 3 (‘Parent/Guardian Statement’).
Child’s Last Name:
First Name:
Middle Initial:
Birthdate (mm/dd/yyyy): Sex:
2
Parent/Guardian Name (please print):
Parent/Guardian, please choose the exemption(s) that apply to your child below.
0 Temporary Medical Exemption
0 Permanent Medical Exemption
0 Personal/Philosophical Exemption (see Box 1)
0 Religious Exemption (see Box 1)
0 Religious Membership Exemption (see Box 2)
Until
Vaccine(s)
Date (or Permanent)
Print Name of Licensed Health Care Provider (MD, DO, ND, PA, ARNP)
X
Signature of Licensed Health Care Provider
X
Date
I do not want my child to get the following vaccine(s):
0 Diphtheria
0 Measles
0 Pneumococcal
0 Tetanus
0 Other (indicate):
Box 1
2
Provider Statement : “I,
, am
a qualified provider (MD, DO, ND, PA, ARNP) licensed under Title 18
RCW. I confirm that the parent or guardian signing in Box 3
(Parent/Guardian Statement) has received information on the benefits
and risks of immunization to their child as a condition for exempting
their child for medical, religious, personal, or philosophical reasons.”
X
Signature of Licensed Health Care Provider (MD, DO, ND, PA, ARNP)
X
Date
0 Hepatitis B
0 Hib
0 Mumps
0 Pertussis (whooping cough)
0 Polio
0 Rubella
0 Varicella (chickenpox)
Box 2
Parent/Guardian Demonstration of Religious Membership: “I am a
member of a church or religious body whose beliefs or teachings do not allow
for medical treatment from a health care practitioner. By supplying the
information requested below, no further proof or signed provider statement in
Box 1 is required for this religious exemption.”
X
Name of Church or Religious Body
X
Signature of Parent or Guardian
X
Date
Box 3
Parent/Guardian Statement: “I certify that all the information provided on this certificate is correct and verifiable. I understand that if there is an
outbreak of a vaccine-preventable disease my child has not been fully immunized against (as indicated above, for medical, personal/philosophical or
religious reasons), my child may be at risk for disease and can be excluded from school, child care, or preschool until the outbreak is over.”
X
Signature of Parent or Guardian
X
Date