Re-enrollment Packet Step 1 of 10 10% Student Name* Legal First Name Middle Legal Last Name Gender*MaleFemaleGrade Level*Please enter a number from 1 to 12.Date of Birth* MM slash DD slash YYYY Place of Birth* City, State, CountryAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County* In what county do you reside within your state?Mailing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code If different than residenceMailing Address County In what county do you reside within your state?Student Home Phone*Student Cell/ Work PhoneStudent's Email Address Residence: Where is your child/family currently living? (Federally mandated by NCLB)*Foster Family Home/ Kinship PlacementIn a motel/hotelLicensed Children's Institution (Group Home)Permanent residence (house, apartment, condo, mobile home)Temporarily Doubled-up (sharing housing with other families/ individuals. Caregivers Affidavit Form)Temporarily Unsheltered (car/ campsite)Other (fill in below)If you answered "Other" please enter here. Parent/ Guardian InformationParent/ Guardian/ Caregiver 1* First Middle Last Relationship to Student* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County* Home/ Cell Phone*Employer Work PhoneEmail Address Parent/ Guardian/ Caregiver 2 First Middle Last Relationship to Student Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County Home/ Cell PhoneEmployer Work PhoneEmail Address Court OrdersAre there any court orders restricting the legal rights of either parent?*NoYesCourt document uploadAccepted file types: pdg, png, gif, jpg, Max. file size: 5 MB.If you answered "Yes" to the above question, please upload a copy of the court order.Special Services InformationDoes your child have an IEP?*NoYesCan you provide a recent copy of your child's IEP?*NoYesDid you student have a 504 plan at his/her previous school?*NoYesCan you provide a copy of your child's 504 Plan?*NoYesHas your child been identified for GATE services?*NoYesOther InformationDid the student pass the 8th grade?*NoYesIs there a computer at home?*NoYesIs there Internet access at home?*NoYesHow many times has the student's family moved in the past 12 months?* Student Ethnicity and RaceEthnicity: Mark the ethnicity with which the student most closely identifies:*Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race)Not Hispanic or LatinoWhat is your child's RACE? (Please check up to five (5) racial categories) The above part of the questions 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 race to be.Student Race American Indian or Alaskan Native Asian Indian Hawaiian Guamanian Samoan Other Pacific Islander African American or Black Chinese Laotian Japanese Hmong Korean Tahitian Cambodian Other Asian Vietnamese White (Persons having origins in any of the original peoples of Europe, North Africa, or the Middle East) Previous SchoolsYear First Enrolled in a School in the US* Please list all U.S. Schools attended: (Most recent at top)Name of School* City and State* Dates Attended* Ex: June 2016-August 2019Name of School City and State Dates Attended Ex: June 2016-August 2019Name of School City and State Dates Attended Ex: June 2016-August 2019Name of School City and State Dates Attended Ex: June 2016-August 2019 Enrollment ContinuedThe information below will be used for statistical purposes ONLY. FLEX High School will not use any personally identifying information when reporting these statistics.1. Have you ever been expelled from any school for any reason?*NoYesIf yes, what school and what year? 2. Have you ever been suspended for more than 10 days in any school year?*NoYesIf yes, what school and what year? 3. Are you a ward of the court?*NoYes4. Are you a parent (mother or father) or expecting a child soon?*NoYes5. Have you ever dropped out of school?*NoYesIf yes, which school and what year? 6. Have you ever been referred to a juvenile Truancy Court or been on probation for attendance problems at school?*NoYesIf yes, which school and what year? 7. Were you retained more than once in grades K-8?*NoYesIf yes, from which school(s) and which year(s)? Parent/ Guardian/ Caregiver Education LevelParent/ Guardian/ Caregiver 1 Highest Level of EducationNot a High School GraduateHigh School GraduateI have an AA degreeI have a BA degreeI have a BA degree and post-graduate coursesParent/ Guardian/ Caregiver 2 Highest Level of EducationNot a High School GraduateHigh School GraduateI have an AA degreeI have a BA degreeI have a BA degree and post-graduate coursesReferral InformationWere you referred to our school?*YesNoIf yes, who referred you?Teacher/ CounselorFamily/ FriendOtherN/APlease write the name of the person who referred you: How did you hear about our school?*Internet SearchFacebookNewspaper/ MagazineRadio adTelevision adBus/ Train adBillboardReceived flyer in mailOtherIf other please enter here: Emergency Release FormFather/ Guardian 1 Name* Guardian Company Name/ Occupation Father/ Guardian Business Address Father/ Guardian PhoneMother/ Guardian 2 Name Guardian Company Name/ Occupation Mother/ Guardian Business Address Mother/ Guardian PhoneEmergency ContactsTo The Principal: In case you are unable to reach me during any emergency, you are authorized to contact and, if necessary, release my child to any of the following:Contact 1 Name* Relationship to Student* Contact Phone Number*Contact 2 Name Relationship to Student Contact Phone NumberContact 3 Name Relationship to Student Contact Phone NumberSibling InformationDoes the student have any brothers or sister in school?Sibling 1 Name Gender Year Born School currently attending Over 18?YesNoSibling 2 Name Gender Year Born School currently attending Over 18?YesNoSibling 3 Name Gender Year Born School currently attending Over 18?YesNo Authorization for Emergency Medical TreatmentThe undersigned, legal custodian of, ________________________________________, a minor, hereby authorize the principal or designee, into whose care the aforementioned minor pupil has been entrusted, to consent to any x-ray examination, anesthetic, medical or surgical diagnosis, treatment, and/or hospital care to be rendered to said minor upon the advice of any licensed physician and/or dentist. This authorization shall remain effective for the full school year unless revoked in writing and delivered to said agent(s). I understand that FLEX High School, it's officers, and it's employees, assume no liability of any nature in relation to the transportation of the said minor. I further understand that all costs of paramedic transportation, hospitalization, and any examination, x-ray, or treatment provided in relation to this authorization shall be borne by the undersigned.Health InformationHealth InformationMedications taken by student at home (written authorization from doctor required for school to administer):* Other Health Condition:* What action is to be taken if student has a complication due to his/her allergic condition or other health condition:* Known Conditions: Check all that apply* Asthma Heart Condition Wears hearing aid Wears glasses Bee Sting Allergy Seizures Glasses to be worn at all times Diabetes Known hearing problem Known eye condition/ defect in vision Epilepsy Preferential seating Wears contact lenses None of the above Insurance InformationInsuranceHealth Insurance Carrier: Insurance ID or Policy #: Hospital Preference:* Doctor InformationPhysicianName of Physician Address PhoneVision (list MD) Hearing (list MD) Previous School InformationSchool Last Attended City State My child is enrolled in a Special Education Program:*YesNoCheck all that apply: Special Day Class Learning Disability TMR Resource Class EMR SED Adapted P.E. Visually Impaired Hearing Impaired Other Health Conditions HOUSEHOLD INFORMATION SURVEY FLEX High School is participating in the Community Eligibility Option provision under the National School Lunch Program. Under this option, all children in the school will receive a breakfast/lunch at no charge regardless of completion of this form. However, to determine eligibility for various additional state and federal program benefits that your child(ren)’s school may qualify for, please complete, sign and return this application to your student’s building if your income falls within or below the guidelines listed in the following chart. INCOME GUIDELINES – 185% Guidelines to be effective from July 1, 2021 through June 30, 2022 Persons in Family or Household Size Annual Monthly Twice Per Month Every Two Weeks Weekly 1 $23,828 $1,986 $993 $917 $459 2 $32,227 2,686 1,343 1,240 620 3 $40,626 3,386 1,693 1,563 782 4 $49,025 4,086 2,043 1,886 943 5 $57,424 4,786 2,393 2,209 1,105 6 $65,823 5,486 2,743 2,532 1,266 7 $74,222 6,186 3,093 2,855 1,428 8 $82,621 6,886 3,443 3,178 1,589 Each Additional Member Add $8,399 700 350 324 162 Privacy Act Statement: This explains how we will use the information you give us. The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the last four digits of the social security number of the adult household member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Ohio Works First (OWF) case number or other identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules. In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to: USDA by: mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410 fax: (202) 690-7442; or email: program.intake@usda.gov. This institution is an equal opportunity provider. If any member of your household receives Supplemental Nutrition Assistance Program (SNAP, formerly food stamps) or Ohio Works First (OWF) benefits, provide the name and 10-digit case number for the person who receives the benefits then proceed to Section 4. If no one receives these benefits, start with Section 1.Name: 10-digit Case Number 1. These selections must be completed by the Head of Household or Designee Size of Family*Please enter a number from 1 to 15.Indicate the total number of individuals living in your household, including all adults and children.2. Students Living in the HouseholdStudent information - Complete for each student Pre-K through 12th grade in the household.Person 1 Name First Last Person 1 Birth Date MM slash DD slash YYYY Person 1 School Is this person Homeless, Migrant, Runaway, or Foster?N/AHomelessMigrantRunawayFosterPerson 2 Name First Last Person 2 Birth Date MM slash DD slash YYYY Person 2 School Is this person Homeless, Migrant, Runaway, or Foster?N/AHomelessMigrantRunawayFosterPerson 3 Name First Last Person 3 Birth Date MM slash DD slash YYYY Person 3 School Is this person Homeless, Migrant, Runaway, or Foster?N/AHomelessMigrantRunawayFosterPerson 4 Name First Last Person 4 Birth Date MM slash DD slash YYYY Person 4 School Is this person Homeless, Migrant, Runaway, or Foster?N/AHomelessMigrantRunawayFosterPerson 5 Name First Last Person 5 Birth Date MM slash DD slash YYYY Person 5 School Is this person Homeless, Migrant, Runaway, or Foster?N/AHomelessMigrantRunawayFosterPerson 6 Name First Last Person 6 Birth Date MM slash DD slash YYYY Person 6 School Is this person Homeless, Migrant, Runaway, or Foster?N/AHomelessMigrantRunawayFosterPerson 7 Name First Last Person 7 Birth Date MM slash DD slash YYYY Person 7 School Is this person Homeless, Migrant, Runaway, or Foster?N/AHomelessMigrantRunawayFosterPerson 8 Name First Last Person 8 Birth Date MM slash DD slash YYYY Person 8 School Is this person Homeless, Migrant, Runaway, or Foster?N/AHomelessMigrantRunawayFoster3. Income InformationTOTAL MONTHLY HOUSEHOLD INCOME – Report Income for all members of household excluding foster children. If you have reported a case number above, you do not need to complete this section.1. Gross Monthly Earnings: Wages, Salary, CommissionsPlease enter a number greater than or equal to 0.Enter 0 if no income.2. Monthly Welfare Payments, Child Support, AlimonyPlease enter a number greater than or equal to 0.Enter 0 if no income.3. Monthly Payments from Pensions, Retirement, Social SecurityPlease enter a number greater than or equal to 0.Enter 0 if no income.4. Monthly Dividends or Interest on SavingsPlease enter a number greater than or equal to 0.Enter 0 if no income.5. Monthly Worker’s Compensation, Unemployment, Strike BenefitPlease enter a number greater than or equal to 0.Enter 0 if no income.6. Other Monthly Income (SSI, VA, Disability, Farm, other)Please enter a number greater than or equal to 0.Enter 0 if no income.Total Monthly Household Income (Add lines 1-6)Enter 0 if no income.4. CertificationSIGNATURE - If Income Section is completed, the adult signing the form must also list the last four (4) digits of his or her Social Security number or check the “I do not have a Social Security number” box below. Certification* I certify (promise) that all information on this application is true and that all income is reported. I understand the school will be eligible for certain federal and/or state funds based on the information I give. I understand that the school officials may verify (check) the information. I understand that if I purposely give false information, my child may lose benefits and I may be prosecuted.Head of Household or Designee Name* Head of Household Signature*Today's Date* MM slash DD slash YYYY Last 4 of Social Check here if you do not have a Social Security Number. I do not have a Social Security Number. Head of Household or Designee Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneEmail Address By providing your email address you may be contacted via email by the district. Special Education & English Language Learner Identification Form FLEX admits students of any race, color, and national or ethnic origin. In order to properly place your student in our Independent Studies Program, it is important to answer the following questins.Place of Birth (Country)* USA School Enrollment Date* MM slash DD slash YYYY The first date that this student was enrolled in a K-12 school in the United States.Last School of Attendance* Last School City and State* Ethnicity*CaucasianHispanicFilipinoAsianPacific IslanderNative AmericanAfrican AmericanOther (Enter in box below)If "Other" was selected above, please enter Ethnicity here. Has student ever been expelled from any school for any reason?*YesNoIf yes, what school and what year? Special Education InformationHas the student ever has an IEP (Individual Education Plan) or received Special Education Services?*YesNoIs the student enrolled in the following?* RSP - Resource Specialist Program SDC - Special Day Class None Is the student receiving Speech and Language services?*NoYesDoes the student have a 504 Plan?*NoYesEnglish Language Development InformationHave the student received English Language Development/ ESL instruction?*NoYesWhat language did your child first learn to speak?* What language does your child most frequently speak at home?* What language do you most frequently speak to your child?* What language do the adults in the home most often speak?* Does the student speak fluent English?*YesNoHas the student received any formal English Language Instruction (listening, speaking, reading, or writing)? (English as a secondary language)*YesNo Release of Pupil Information Organization Information To Be Released Press, television, and other organizations Information concerning participation in athletics, other school activities, the winning of scholastic or other honors and awards, and other such information. P.T.A. officers Names, addresses, and telephone numbers of pupils they represent. Colleges and Universities Transcripts, letters of recommendation for admission, scholarships, etc. Employers or potential employers Name, address, age, scholastic record, and staff employment recommendation. Private business or professional schools or colleges approved by the Ohio State Superintendent or Public Instruction Names and addresses of graduating seniors. Official employment of recruitment representatives of private industry; federal, state, and local government agencies; and the military forces of the United States. Career guidance information including names and addresses of graduating seniors. Another school district in which pupil intends to enroll or has enrolled School records and / or transcript of grades and credit. Consent To Release Pupil InformationDo you authorize the release of information on your pupil to organizations and agencies noted above?*I authorizeI do not authorizeSelect one option. Consent to Release Confidential InformationI do hereby consent and authorize my previous school (listed below) to exchange information and share communication in verbal, written, and/or electronic for regarding the student listed below to FLEX High School. I understand that I may revoke this consent at any time by notifying the school in writing. A photocopy of this authorization is to be considered as valid as the original document.Student Name* Previous School* Information for release includes the following: Transcripts/Credit Data Report Card Grades Specific OGT Test Scores Attendance Records Health/Immunization Records Individualized Education Program (IEP) Evaluation Team Report (ETR) Birth Certificate Discipline Records Psychological/ Counseling Reports Psychiatric Evaluations Standardized Test Results Section 504 PlanConfirmation:* I consent and I am the parent or guardian of the student, or I am an adult student. Proof of ResidencyVERIFICATION OF RESIDENCY · A recent utility bill (gas, electric or water) in the parent/guardian’s name (Phone or cable bills are not acceptable). · A current lease agreement with parent/guardian’s name. Name and phone number of the landlord must be provided in order to verify the lease. · Statement from the Department of Human Services or Social Security, on letterhead, indicating the address used by the parent for receipt of checks. Even if the parent has checks delivered to a post office box, the caseworker may be able to provide verification of an address for the parent, on the agency’s letterhead. · Statement from the Personnel Office of parent’s employer, on letterhead, indicating the address used by the parent for employment purposes and for submission of Internal Revenue Service (IRS) W-2 forms. · Change of custody forms on Franklin County Child Services (FCCS) letterhead or court documents indicating a change of custodial parent (and address). These must be filed with the Division of the Registrar prior to the child being enrolled in FLEX High. If the child is already enrolled and will continue current assignment, the new custodial parent will need to go to the Division of the Registrar Office to file paperwork.Proof of Residency*Accepted file types: pdf, jpg, png, jpeg, Max. file size: 8 MB.ConsentParent/ Guardian/ Adult Student Name* Relationship to Student* Parent / Guardian / Adult Student Signature*Today's Date* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged. Written By: Aimee Buchanan Share Article: Tags: school_center Previous Article Next Article
