Enrollment Forms Packet (EFP)Please review the information below. Based on your student(s) grade and applicable circumstances, you are required to submit documenta-tion in order to complete this step in the enrollment process. You can fax, scan and email, or mail the required paperwork .

Important Note: Please send copies, do not mail the original documents

Fax (preferred): Scan and Email: Mail: 1-877-554-1088 covafax@k12.com Colorado Virtual Academy 11990 Grant Street Suite 402 Northglenn, CO 80233

Colorado Virtual AcademyEnrollment Processing Center2300 Corporate Park Drive Ste 200 Herndon, VA 20171Ph. 866.339.6814Fx. 877.554.1088www.k12.com/cova

Required For? Item Description Provided by?

Required for all Students

Proof of Age Official Birth Certificate (not the hospital issued certificate) Provided by you

Proof of Residency

Utility bill (electric, water, gas) showing current address. This document must include a current date to show service after March 1st, a complete “service address” and must match address on enrollment packet and include Legal Guardian name. Please indicate name of student on document. Do not send cell phone bill, tax return, miscellaneous mail.

Provided by you

Immunization Record

A copy of your student’s Immunization Record or a signed exemption waiver. For more information about required immunizations go to http://www.cdphe.state.co.us/dc/Immunization/combine22new.pdf.

Provided by you

Affidavite of State of Coloado Residency Please complete and sign this document. 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

Internet Use Policy Agreement

This form must be signed by the Legal Guardian for all Students and also have the student signature for all students in the 4th grade or higher.

Provided in this packet

Family Data Survey Directions to assist you in completing this form are provided in the Enrollment Forms Packet.

Provided in this packet

Out of District Waiver Form Only sign and submit this form if you do not reside in Adams County District 12. Provided in this

packet

Home Language Survey Please complete and sign this document. Provided in this

packet

Report Card/Unof-ficial Transcript

The most recent Report Card/Transcript, except for students enrolling in Kinder-garten.

Provided by you

Household Enroll-ment Form Please complete this form and submit. Provided in this

packet

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

Proof of Age Cover Sheet

Please place a copy of the student

Official Birth Certificate (not the hospital issued certificate)

behind this sheet

Send this form to: Colorado Virtual Academy By Fax: 1-877-554-1088 By Mail: 11990 Grant St. STE 402, Northglenn, CO 80233 By Email: covafax@k12.com Questions? Call 303-255-4650

Affidavit of State of Colorado Residency

Student’s Name: ________________________________________________________________ First Name Middle Name Last Name Pursuant to 1CCR301-71, Rules for the Administration, Certification and Oversight of Colorado Online Programs, the Colorado State Board of Education must ensure that student residency is documented and verified, both upon initial enrollment and annually thereafter. Colorado residency is determined by the student and Parent or legal guardian currently residing within the State of Colorado boundaries, except for student of military families that maintain Colorado as their state of legal residence for tax and voter registration purposes. Reasonable evidence of residency within the State of Colorado boundaries can be established by a written statement of residency from the student’s parent/guardian pursuant to Section 8.06.4.

Affidavit by Parent or Legal Guardian Please complete the below affidavit and submit documentation to Colorado Virtual Academy evidencing your residency for the Colorado State Board of Education. Addresses cannot be post office boxes or general delivery at a post office and must match the home address that Colorado Virtual Academy has on file for this affidavit to be valid. I,___________________________________________ , do hereby swear and affirm, under penalty of perjury, that my child(ren) and me are currently and will continue to be residents of the State of Colorado for the 2013/2014 school year.

Parent/Legal Guardian Signature Date

Only physical signatures are acceptable. Please complete the form, print out, sign and fax or email.

Please print your full name and address below (completing all blanks): Parent/Legal Guardian’s Full Name Street Address (Address cannot be post office box or general delivery at a post office. No vacant lot or business address shall be considered a residence.)

Apartment/Unit# County

City State ZIP Code

Please print full legal names of all your children who are enrolled and/or enrolling at Colorado Virtual Academy below:

Colorado Virtual AcademyEnrollment Processing Center 2300 Corporate Park DriveSuite 200Herndon, VA 20171Ph. 866.339.6814Fx. 877.554.1088www.k12.com/cova

Student InformationStudent’s Full Name:

first middle last

Student’s Date of Birth:

Student’s Legal Address: street apt #

city county state zip

Home Phone:

Check below if applicable: o Student was always previously homeschooled

o Student is enrolling in Kindergarten

Name of Prior School:

School’s Address: street

city county state zip

School’s Phone: School’s Fax:

Name of Parent or Legal Guardian: first last

Parent/Guardian’s Signature: Date:

Release of Student RecordsPlease accept this document as formal approval for the release of all official school records (including the record of transcripts, testing information, special education, health and immunization records).

Homeschooled or Never Previously Enrolled in School (Fill out only if applicable)

Prior School Information

Sign and Date below

SCHOOL OFFICIALS ONLY:

Send student records to: Washington Virtual Academies 1584 McNeil Street, Suite 200 DuPont, WA 98327

SCHOOL OFFICIALS ONLY:

Send student records to: Virginia Virtual Academy 2300 Corporate Park Drive, Suite 200 Herndon, VA 20171

SCHOOL OFFICIALS ONLY:

Colorado Virtual Academy 11990 Grant Street, Suite 402 Northglenn, CO 80233 fax: 877-554-1088

Student’s Name: Student’s Home Phone:

Colorado Virtual AcademyEnrollment Processing Center 2300 Corporate Park DriveSuite 200 Herndon, VA 20171

Ph. 866.339.6814Fx. 877.554.1088www.k12.com/cova

Internet Use Agreement

INTERNET USE AGREEMENT

IntroductionWe are pleased to offer students of Colorado Virtual Academy access to computer network resources, electronic mail and the Internet. To use these resources, all students must sign and return this form, and those under age 18 must obtain parental permission. Parents, please read and complete this document carefully, review its contents with your son/daughter, and sign and initial where appropriate.

General Network UseThe network is provided for students to conduct research, complete assignments, and communicate with others. Access to network services is given to students who agree to act in a considerate and responsible manner. Students are responsible for good behavior on school computer networks just as they are in a classroom or a school setting. Access is a privilege - not a right. As such, general school rules for behavior and communications apply and users must comply with standards and honor the agreements they have signed. Beyond the clarification of such standards, COVA is not responsible for restricting, monitoring or controlling the communication of individuals utilizing the network.

Network storage areas may be treated like school lockers. Network administrators may review files and communications to maintain system integrity and insure that users are using the system responsibly. Users should not expect that files stored on district servers will always be private.

Internet / World Wide Web / E-mail AccessAccess to the Internet and e-mail will enable students to use thousands of libraries and databases. Within reason, freedom of speech and access to information will be honored. Families should be warned that some material accessible via the Internet might contain items that are illegal, defamatory, inaccurate or potentially offensive to some people. While our intent is to make Internet access available to further educational goals and objectives, students may find ways to access other materials as well. Filtering software is in use, but no filtering system is capable of blocking 100% of the inappropriate material available on the Internet. We believe that the benefits to students from access to the Internet, in the form of information resources and opportunities for collaboration, exceed any disadvantages. Ultimately, parents and guardians of minors are responsible for setting and conveying the standards that their children should follow when using media and information sources.

Publishing to the World Wide WebParents, your daughter or son’s work may be considered for publication on the World Wide Web, specifically on his/her school’s web site. Such publishing requires parent/guardian permission (see over). The work will appear with a copyright notice prohibiting the copying of such work without express written permission. In the event anyone requests such permission, those requests will be forwarded to the student’s parent/guardian.

Unidentified photos of students may be published on school websites, illustrating student projects and achievements. In addition, your daughter or son’s full name may be considered for publication on his/her school’s web site. If published, his/her name will appear on pages with a clear school related purpose and will be included to further instructional and/or co-curricular activities. Permission for such publishing does not grant permission to share any other information about your son/daughter, beyond that implied by their inclusion on the web page(s). If you do not want your child’s photo or name to be published on the website, please indicate this on the Release of Information form (Photo/Video Release portion), which can be found included in your enrollment packet.

To use networked resources, all students must sign and return this form, and those under age 18 must obtain parental permission. The activities listed below are not permitted: -Sending or displaying offensive messages or pictures -Using obscene language -Giving personal information, such as complete name, phone number, address or identifiable photo, without permission from teacher and parent or guardian -Harassing, insulting or attacking others -Damaging or modifying computers, computer systems or computer networks -Violating copyright laws -Using others’ passwords -Trespassing in others’ folders, work or files -Intentionally wasting limited resources -Employing the network for commercial purposes, financial gain, or fraud violations may result in a loss of access as well as other disciplinary or legal action.

Student’s Name: Student’s Home Phone:

12

Internet Use Agreement Colorado Virtual Academy

Student User Agreement: As a user of the Colorado Virtual Academy/K12, Inc. computer network, I hereby agree to comply with the statements and expectations outlined in

this document and to honor all relevant laws and restrictions.

(Initial appropriate items) I agree to use the network responsibly

I grant permission to have my materials published to the World Wide Web

Student Signature: Date:

Parent/Guardian Permission: All students are provided with access to school computer resources. In addition to accessing our computer network, as the parent or legal

guardian, I grant permission for the above named student to:

(Initial appropriate items) access the Internet and e-mail systems

have his/her materials published to the World Wide Web

These permissions are granted for an indefinite period of time, unless otherwise requested. I understand that individuals and families may be held liable for violations. I understand that some materials on the Internet may be objectionable, but I accept responsibility for guidance of Internet use - setting and conveying standards for my daughter or son to follow when selecting, sharing or exploring information and media.

Parent Signature: Date:

Student’s Name: Student’s Home Phone:

13

Colorado Virtual AcademyEnrollment Processing Center 2300 Corporate Park DriveSuite 200Herndon, VA 20171Ph. 866.339.6814Fx. 877.554.1088www.k12.com/cova

Out-of-District Waiver

Student’s Name: last first middle

Parent/Guardian’s Name: first last

Parent/Guardian’s Address:

street apt #

city county state zip

Please accept this waiver as my confirmation that enrollment in the Colorado Virtual Academy, a charter school in Adams County District12, does not entitle my student to attend any other Adams County District 12 schools due to withdrawal or expulsion. I specifically waive any such right.

Parent/Guardian’s Signature: Date:

Please complete one form for each student to be admitted to COVA. Note: This form must be completed and signed for students who reside outside of Adams County School District 12.

Student’s Name: Student’s Home Phone:

Home Language Survey Colorado Virtual Academy

2013-2014

Schools must develop equal opportunities for any student whose dominant language is not English. In order to do this, Federal

and State regulations require schools to determine the language(s) spoken and understood by each student.

Student Name (please print) Parent or Guardian Name (please print)

Home Address (street) (city) (state) (zip) Birthdate:

Month / Day / Year 1. What language or languages did your child speak

when he/she first began to talk? ________________________________________

4. Do the adults in our home (parents, guardians, grandparents or any other adults) speak to each other in a language other than English daily?

□ Yes □ No

2. Please describe the language spoken by your child.

_______a. Speaks only the other language and no English.

_______b. Speaks mostly the other language and some English.

_______c. Speaks the other language and English equally

_______d. Speaks mostly English and some of the other language

_______e. Speaks only English

If yes, what language or languages? ___________________ Does your child understand the conversations?

□ Yes □ No

Does your child participate in the conversations? □ Yes □ No

5. Did your child attend school in another country?

□ Yes □ No If yes, how many years? ____________________ Which country? ___________________________

Language or languages used in instruction:

________________________________________

3. Please describe the language understood by your

child (Check only one)

______a. Understand only the other language and no English

______b. Understands mostly the other language and some English

______c. Understand the other language and English Equally

______d. Understands mostly English and some of the other language

______e. Understands only English.

Parent/Guardian Signature Date

Is there any information you would like to share with us regarding your child’s language/s? (e.g. child was adopted from a foreign country; child learned second language in a foreign language class; etc.)

Student Name: Phone:

Colorado Virtual Academy Household Enrollment Form (this document is required for submission to Adams 12 Five Star Schools)

PARENT/GUARDIAN WHO RESIDE WITH STUDENT(S) (where student resides majority of the time) Resident Street Address City

State

Zip County Home Phone

Mailing Address (if different than above)

We prefer our correspondence in: □ English □ Spanish Other: _____________________

City

State Zip County

Parent/Guardian Last Name

Parent/Guardian First Name Gender □ M □ F

Work Phone

Cell Phone Email Address DOB

Parent/Guardian Last Name

Parent/Guardian First Name Gender □ M □ F

Work Phone

Cell Phone Email Address DOB

SCHOOL AGED CHILDREN* RESIDING WITH PARENT/GUARDIAN IN THE ABOVE HOUSEHOLD *Include student(s) enrolling

Student Legal Last Name Student Legal First Name Grade Current School New School

CURRENT RESIDENCE STATUS (where student resides majority of the time) Residency is important as it can directly relate to rights under the McKinney-Vento Homeless Assistance Act

□ House/apt/Condo/Townhouse/Duplex □ Motel/Hotel □ Campground/RV/Car □ Emergency Shelter

□ Transitional Housing Program □ Are you living with friends or family due to the loss of housing of financial hardship? □ Are you a student not living with parent or legal guardian? □ Other, please describe _________________________

Student Name: Phone:

SECONDARY HOUSEHOLD PARENT/GUARDIANS WHO RESIDE AT ANOTHER ADDRESS

Resident Street Address City

State

Zip County Home Phone

Mailing Address (if different than above)

We prefer our correspondence in: □ English □ Spanish Other: _____________________

City

State Zip County

Parent/Guardian Last Name

Parent/Guardian First Name Gender □ M □ F

Work Phone

Cell Phone Email Address DOB

Parent/Guardian Last Name

Parent/Guardian First Name Gender □ M □ F

Work Phone

Cell Phone Email Address DOB

SCHOOL AGED CHILDREN* RESIDING WITH PARENT/GUARDIAN WHO RESIDE AT ANOTHER ADDRESS *Include student(s) enrolling

Legal Last Name Legal First Name Grade Current School New School (if applicable)

NON-HOUSEHOLD EMERGENCY CONTACT INFORMATION The following person are authorized to give consent for urgent health, dental, surgical procedures or hospital care for my child in the event staff

cannot reach an authorized parent/legal guardian Priority Contact Name

(First – Last) Gender Relationship to Student Home Phone Cell Phone

1. 2. 3. 1. Please note that federal law requires that educational records concerning a child be shared with a parent regardless of his/her custody status or decision making authority absent a court order limiting such disclosures. Please submit such court order if applicable. 2. By default, parents who reside at both the primary household and secondary household will be allowed to pick up the child from school. 3. Be aware that without prior notice or verification, students will not be released early during the day to anyone other than a parent/legal guardian. Print Parent/Guardian Name (please print) ____________________________________________________________________________

Parent/Guardian Signature ________________________________________________________________ Date: ____________________

11990 Grant Street, Northglenn, CO 80233 Office: (303) 255-4650 Fax: 1-877-554-1088 Email: covafax@k12.com Together – educating the whole child

2013-2014 FAMILY ECONOMIC DATA SURVEY FOR ALTERNATE PROGRAM FUNDING/ELIGIBILITY

INSTRUCTIONS

This survey is used by Adams 12 Five Star Schools to maximize available funding from state and federal sources, as well as to provide certain other benefits that may be available for your child. In many cases, the eligibility for these funds and programs is linked to whether or not your child is currently eligible for free or reduced price meals in the federal School Lunch (and Breakfast) programs. Colorado Virtual Academy does not participate in the federal School Lunch or Breakfast Programs. For this reason, we are asking that you complete the attached survey as an alternate means of qualifying your child’s school for state and federal programs that will provide much needed funding. Additionally, this may also qualify your child for certain other benefits. Complete one survey per student at COVA if:

• Your household size and income are within the limits on the Income Chart below, or • Your family receives SNAP (formerly the Food Stamp Program) or FDPIR benefits

(Supplemental Nutrition Assistance Program, or Food Distribution Program on Indian Reservations), or

• You have a foster child.

Income Chart

Household Size Yearly Monthly Weekly

1 $21,257 $1,772 $409 2 $28,694 $2,392 $552 3 $36,131 $3,011 $6954 $43,568 $3,631 $8385 $51,005 $4,251 $981 6 $58,442 $4,871 $1,124 7 $65,879 $5,490 $1,24678 $73,316 $6,110 $1,410

For each additional family member add:

$ 7,437 $620 $144

2013-2014 Family Economic Data Survey For alternate Funding/ Eligibility

Last Name(s) of Family Property Mailing Address, City, Zip Code (Not a PO Box) Telephone Number

INSTRUCTIONS: Using the instruction sheet provided, complete the application, sign your name, and return the application to the school.

************************Do Not Write Below This Line. District Use Only.*************************

Part 1. Student Information. List student attending Colorado Virtual Academy: provide school and grade information. Check the foster child check box for all students that are the legal responsibility of a welfare agency or court.

Student income; please provide income information for student. This is income that is received by the student only.

Last Name, First Name School Grade Foster Child

No Income

Earnings from work before deductions, or unemployment Welfare, child support Social Security and Other

COVA monthly bi-weekly $ . weekly 2x/month

monthly bi-weekly $ . weekly 2x/month

monthly bi-weekly $ . weekly 2x/month

Part 4. List all household members not listed above

List all current gross income and check how often it was received.

Name No Income

Earnings from work before deductions, or unemployment Welfare, child support, alimony Pensions, retirement,

Social Security Other

monthly bi-weekly

$ . weekly 2x/month monthly bi-weekly $ . weekly 2x/month

monthly bi-weekly $ . weekly 2x/month

monthly bi-weekly $ . weekly 2x/month

monthly bi-weekly

$ . weekly 2x/month monthly bi-weekly $ . weekly 2x/month

monthly bi-weekly $ . weekly 2x/month

monthly bi-weekly $ . weekly 2x/month

monthly bi-weekly

$ . weekly 2x/month monthly bi-weekly $ . weekly 2x/month

monthly bi-weekly $ . weekly 2x/month

monthly bi-weekly $ . weekly 2x/month

monthly bi-weekly

$ . weekly 2x/month monthly bi-weekly $ . weekly 2x/month

monthly bi-weekly $ . weekly 2x/month

monthly bi-weekly $ . weekly 2x/month

monthly bi-weekly

$ . weekly 2x/month monthly bi-weekly $ . weekly 2x/month

monthly bi-weekly $ . weekly 2x/month

monthly bi-weekly $ . weekly 2x/month

monthly bi-weekly

$ . weekly 2x/month monthly bi-weekly $ . weekly 2x/month

monthly bi-weekly $ . weekly 2x/month

monthly bi-weekly $ . weekly 2x/month

Part 3. If the student you are applying for is homeless, migrant, or runaway, please call Adelita Sandoval 303-255-4650 x5007.

Part 7. Signature and Social Security Number: (Adult MUST sign) An adult household member must sign the application.

I certify (promise) that all information on this application is true and that all income is reported. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, I may be prosecuted.

Sign here: X Date: _____________________

Part 5. MEDICAID AND/OR STATE CHILDREN’S HEALTH INSURANCE PROGRAM (SCHIP)—The information provided in the application may be shared with Medicaid or SCHIP offices to seek enrollment of children into the above programs. You are not required to consent to the disclosure of this information. Your information WILL be shared unless you

check the box below.

Please do NOT share my information with the Medicaid or SCHIP offices.

Part 2. Supplemental Nutrition Assistance Program (SNAP) / Food Distribution Program on Indian Reservations (FDPIR): Provide the name and case number for the person who receives benefits. (Enter information and skip to part 5)

Name: Case Number:

Annual Income Conversion: Weekly x 52; Bi-Weekly x 26; 2 Times per Month x 24; Monthly x 12 Total Income: Per Week, Bi-Weekly, 2x/Month, Month, Year Household size: Eligibility: Free _____Reduced ___________ Denied ________ Reason: _________________________________________________ Determining Official’s Signature: Date: Student ID: ________________ Family ID: ___________ IC ID: ____________

IF YOUR HOUSEHOLD RECIEVES BENEFITS FROM SNAP (SUPPLMENTAL NUTRITION ASSITANCE PROGRAM OR FDPIR (FOOD DISTRIBUTION PROGRAM ON INDIAN RESERVATIONS), FOLLOW THESE INSTRUCTIONS:

Part 1: List student; indicate school and grade for student. Part 2: List the name of the household member receiving the benefit, and list the case number. Part 3: Skip this part Part 4: Skip this part Part 5: If you do not want your information shared with Medicaid or SCHIP, check this box. Part 7: An adult household member must sign the form.

If you are applying for a MIGRANT, HOMELESS, OR RUNAWAY CHILD, please call Adelita Sandoval, 303-255-4650 x5007. Indicating homeless, migrant, or runaway on this application DOES NOT qualify the student for meal benefits; the coordinator must be contacted.

IF YOU ARE APPLYING FOR A FOSTER CHILD ONLY FOLLOW THESE INSTRUCTIONS:

Part 1: List student; indicate school and grade for student. Check the foster check box for foster child. Part 2: Skip this part Part 3: Skip this part Part 4: Skip this part Part 5: If you do not want your information shared with Medicaid or SCHIP, check this box. Part 7: An adult household member must sign the form.

FOR ALL OTHER HOUSEHOLDS, INCLUDING WIC AND HOUSEHOLDS THAT HAVE FOSTER CHILD(REN) LIVING WITH THEM ALONG WITH NON-FOSTER CHILD(REN), FOLLOW THESE INSTRUCTIONS:

Part 1: List child’s name, school, and grade. If the child is a foster child, check the foster box. For student listed, please indicate income information including source and frequency of pay, or indicate no income.

Part 2: Skip this part. Part 3: Skip this part. Part 4: Follow these instructions to report all household income. Income can be from the previous month, this month, or your

projected income for next month. Column 1–Name: List the first and last name of each person living in your household, related or not (such as grandparents, other relatives, or friends). You must include yourself and all children living with you not listed in Part 1. Attach another sheet of paper if you need to. Column 2–Check if no income: If the person does not have any income, check the box. Column 3–6 Gross income and how often it was received: Next to each person’s name, list each type of income received and how often it was received.

Earnings from work: example: If you are paid $500.00 bi-weekly, please record $500.00 in the income blank and mark the bi-weekly check box. Gross income is the amount earned before taxes and other deductions.

Additional Income Sources: List the total amount each person received from all other sources. For example: If you receive $500.00 monthly for child support, please record $500.00 in the income blank and mark the monthly check box.

Other Income: Report net income for self-owned business, farm, or rental income. Next to the amount, check how often the person receives it. If you are in the Military Housing Privatization Initiative, do not include this housing allowance.

Part 5: If you do not want your information shared with Medicaid or SCHIP, check this box. Part 7: An adult household member must sign the form.

INCOME TO REPORT:

Earnings from Work Wages/salaries/tips Strike benefits Unemployment Compensation Worker’s Compensation Net income from self- owned business or farm

Welfare/Child Support/Alimony Public assistance payments Welfare payments Alimony Child support payments

Pensions/Retirement/ Social Security Pensions Supplemental Security Income Retirement income Veteran’s payments Social Security

Other Income Disability benefits Cash withdrawn from savings Interest/Dividends Income from Estates/Trusts/ Investments Regular contributions from people not living in the household Net royalties/annuities/ net rental income Any other income