GUIDELINES FOR

REGISTRATION AND

ENROLLMENT OF STUDENTS

DISTRICT SCHOOL BOARD OF COLLIER COUNTY

Dr. Kamela Patton

Superintendent of Schools

2012-2013

www.collierschools.com

Dr. Kamela Patton Superintendent of Schools

THE DISTRICT SCHOOL BOARD OF COLLIER COUNTY

Roy M. Terry, Chair

Barbara Berry, Vice Chair Patricia M. Carroll, Member Kathleen Curatolo, Member

Julie Sprague, Member

This report has been prepared by The District School Board of Collier County. Additional copies, if available, may be obtained by writing:

The District School Board of Collier County

Dr. Martin Luther King, Jr. Administrative Center Student Services

5775 Osceola Trail Naples, Florida 34109-0919

Report Number: Coordinated by: 05011201 Mrs. Christy Kutz

No person in this district shall, on the basis of race, national origin, sex, disability, marital status, religion, or age, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any education program

or activity, or in employment conditions or practices conducted by The District School Board of Collier County.

VISION STATEMENT

All students will complete school prepared for ongoing learning as well as community and global responsibilities.

For questions or complaints (adults) regarding the Educational Equity Act, Title IX, Section 504 (Rehabilitation Act), or the Americans with Disabilities Act, contact Debbie Terry, Executive Director of Human Resources, (239) 377-0344. For questions or complaints (students) regarding the Educational Equity Act, Title IX, or The Age Discrimination Act of 1975, contact Dr. Diedra Landrum, Coordinator of Student Services/Guidance & Counseling, (239) 377-0517. For questions or complaints (students) regarding Section 504 (Rehabilitation Act) and the Americans with Disabilities Act, contact Dr. L. Van Hylemon, Coordinator of Psychological Services (239) 377-0521. The address for the above contacts is: The District School Board of Collier County, 5775 Osceola Trail, Naples, Florida 34109.

GUIDELINES FOR

REGISTRATION AND

ENROLLMENT OF STUDENTS

Mrs. Christy Kutz Director of Student Services

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TABLE OF CONTENTS

Part I: New Student Registration PK-12

1. Enrollment Requirements

Proof of Residency ...............................................................................................................2 School Health Requirements................................................................................................4 Social Security Information .................................................................................................6 Proof of Age .........................................................................................................................7 Kindergarten ........................................................................................................................7 First Grade ...........................................................................................................................8 High School: Regular Students, Students over age 16 or Emancipated Minors ..................9 Homeless Students .............................................................................................................10 Students with Expulsions and Arrests................................................................................11 Temporary Enrollment of Student for Testing Purposes Only ..........................................11

Part II: Transfer Students 2. Enrollment

Students Entering from another School In-County ............................................................12 Students from Out-of-County, Out-of-State or Out-of-Country ........................................12

3. Withdrawal

Students Transferring In-County .......................................................................................12 Students Transferring Out-of-County or Out-of-State .......................................................12 High School Students Withdrawing with a Dropout Withdrawal Code ............................13 Procedures for Checking Students Out of School during the School Day ........................13

Part III: Students from Foreign Countries

4. VISA’s, I-20’s and Foreign Exchange Students ................................................................14

Part IV: Appendix

Appendix A Student Enrollment form ....................................................................16 Appendix B Annual Student Emergency Information Card ...................................22 Appendix C Statement of Acceptance of Liability and

Responsibility for School Age Children Form ...................................28 Appendix D Sworn Statement Verifying Birthdate ................................................31 Appendix E Certificate of Age (physician's affidavit) ...........................................32 Appendix F Policy 5112.01 Maximum Age for Participation in the

Regular High School Program ...........................................................33 Appendix G Declaration of Intent to Terminate School Enrollment ......................34 Appendix H Memo: Registration and Enrollment – Power of Attorney ................37 Appendix I High School Exit Interview ................................................................38

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Part I: New Student Registration PK-12

This booklet has been developed in order to standardize enrollment procedures throughout the Collier County Public Schools. Additional information on enrollment should be directed to the Department of Student Services at 377-0505. All children who have attained the age of 6 years or who will have attained the age of 6 years by February 1 of any school year or who are older than 6 years of age but who have not attained the age of 16 years, except as otherwise provided, are required to attend school regularly during the entire school term. Florida Statute s.1003.21 (1) (a) Additionally, a child who attains the age of 16 during the school year is not subject to compulsory school attendance beyond the date upon which he or she attains that age, if the child files a formal declaration of intent to terminate school enrollment with the District School Board. The student must meet with the Principal or designee for an exit interview before submitting an intent to terminate school enrollment. The declaration must acknowledge that terminating school enrollment is likely to reduce the student’s earning potential and must be signed by the child. The school district must notify the child’s parent or legal guardian of the child’s declaration of intent to terminate school enrollment. (See Appendix G)

Enrollment To enroll a child in Collier County Public Schools, a parent or guardian must complete:

• Student Registration form (Appendix A), and • Annual Student Emergency Information Card (Appendix B) at the school site.

The parent/guardian must also provide the school with the required documentation for residency (1+2 proofs), health requirements (immunization certificate, physical examination), and proof of age (see pages 2-6). The complete name, address, ZIP code, and phone number of any school the student previously attended, along with the last report card or withdrawal form must be provided. If divorced, a copy of the decree and any current legal documents that apply to the parents’ rights as they relate to the child at school (such as restraining order or school pick-up) must be provided to the school. To ensure that school staff may identify and locate students from the TERMS database, school staff must enter student information in TERMS on panel S313 and a class enrollment on S614 as soon as possible. Proof of Residency The District will request information regarding residency to determine the location of the student’s domicile but not as it relates to citizenship or immigration status.

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The place of residence for the child is deemed to be that place, with address specific, where the parent(s) or guardian eats and sleeps on a continuous basis. A student and his parents cannot occupy a residence at more than one address. Parents or guardians may prove residency by providing ONE of the following:

• Homestead Exemption Card reflecting Homestead Exemption within Collier County(considered family’s primary residence)

• Property Tax Notice (may require additional verification) • Home Purchase Contract in Collier County specified closing date , with a copy of

the deed to be provided within 60 days of closing date • Copy of a Manifestation of Domicile filed by the parent (obtained at the Collier

County Courthouse/The Clerk of Courts Office) • A current rental or lease agreement

AND TWO of the following:

• A current Florida driver license or Florida Identification Card • Automobile Insurance (last two statements) • A current electric billing statement, bottom portion showing name and service

address • Water bill or Cable bill or Landline Phone Bill (last two statements)

(*New residents may provide set up of service for 2 utilities with name and address for enrollment. Within 60 days must provide first 2 months bills to school) 1. If a parent would like their child to attend a school other than their home zoned

school they must submit a request to the Choice and Out of Zone Specialist (form is available on the district website). Out of zone attendance must also be approved before the student’s enrollment is completed.

2. Parents who live with someone else must provide:

• Notarized letter from person they are living with stating that the parent and child live there. Notarized confirmation from parent(s) that they (he/she), in fact, live with such person.

• 3 Proofs of address from person who wrote the letter to establish that they live in the school zone.

• 3 Proofs of address from the parent to verify that they live at the address. 3. Parents whose child lives with someone else (see Appendix H) must provide:

• Notarized Power of Attorney that includes the following information must be submitted to the Department of Student Services by the school or parent for review prior to enrollment. o Relationship of guardian to child o States that guardian will be responsible for the child’s educational needs. o Length of temporary guardianship

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• Department of Student Services will notify the school regarding status of enrollment.

• If Student Services approves enrollment of the child by the guardian: o Guardian must sign district Statement of Acceptance of Responsibility Form.

(Appendix C) o Parent or guardian must provide evidence of pursuit of legal custody through

the courts to the school within 90 days (school will note on TERMS S313 Screen).

o Student Services will follow-up with district letter to parent/guardian and school, as needed.

4. Homeless student information is available by contacting the Homeless Liaison at 239-

377-0544. 5. Should a student move, proof of residency must be provided as stated above. The

following items are evidence a move is full and complete: a. The former residence is not occupied for any purpose as any time by the

student or any of the persons with whom the student has been living; and b. All personal belongings are moved from the former residence: and c. Mail is received at the new residence; and d. All utilities are transferred to the new residence; and e. Driver license, voter registration and other forms of legal identification are

changed to the new residence.

Notice Students whose parents are found, after appropriate investigation, to have submitted fraudulent information in an effort to enroll a student in a school to which the student is not assigned shall be immediately withdrawn and referred for enrollment in the appropriate boundaried school.

School Health Requirements Certification of a physical examination and current immunizations is required.

• Students must produce a DH 680 Form on white or blue paper which is the only document schools accept as proof of immunization. Private Physicians and the Health Department can provide this form. An electronic DH 680 on white paper is valid if it conatins an electronic signature, the Florida State seal is imbedded in the background, the Florida Shots logo is in the bottom right corner, and a unique identifier number is located under the provider name.

• The Religious Examption from Immunizations form (DH 681) is only granted by county health departments. • No Student may attend school without proper documentation of immunization or

exemption. • Florida Statue requires that all students entering Florida schools for the first time

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present a certificate of physical examination performed within twelve (12) months prior to enrollment.

Immunizations

Florida Statute 1003.22 requires that all students entering Florida schools must present proper documentation of immunization or exemption. No child may attend school without proper documentation of immunization or exemption. No exemption period is permitted while waiting for transfer of records (A homeless child, as defined in F.S. 1003.01, shall be given a temporary exemption for up to 30 school days. An exemption for up to 30 days may also be issued for a student who enters a juvenile justice program to permit the student to attend class until his or her records or the actual immunization can be obtained.) The public school nurse or authorized private school official is responsible for follow up of each such student until proper documentation or the actual immunizations are obtained. Only the standard Florida Department of Health Certificate of Immunization is acceptable. This may be obtained from a private physician or the County Health Department. Parents must obtain the standard approved Florida Department of Health forms before a student may be enrolled. The Collier County Health Department provides required immunizations free of charge.

Electronically transferred records (FASTER) containing a student’s completed immunization information are acceptable forms of documentation for students transferring from one Florida school district to another. A copy of the actual paper certificate must be forwarded for the student record. School nurses may download completed Florida Certificates of Immunization from Florida Shots. Schools must refuse admittance to and temporarily exclude any child otherwise entitled to admittance to kindergarten, or any other entrance into a Florida public or private school, who is not in compliance with the provisions of the law regarding immunization against communicable disease. A student must be excluded from school until they can provide proof of immunization against communicable disease or a certificate of exemption. Students whose parents do not present a new certificate after expiration of a temporary certificate must also be excluded from school. It is strongly recommended that a tickler file system be developed in schools to help track students with temporary immunization certificates for students who are homeless or in Department of Juvenile Justice facilities.

Any child whose parent or guardian presents a Religious Exemption from Immunizations Form may be granted exemption from the immunization requirement. This Religious Exemption from Immunization Form is only issued by the County Health Department. Physical Examinations

Florida Statute 1003.22 requires that all students entering Florida Schools for the first time present a certificate of physical examination performed within twelve (12) months prior to enrollment. The Florida DH 3040 form is recommended to document a physical examination however any record may be used that includes at minimum all the elements contained in the form DH 3040.

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Although this is a one-time requirement for grades PK-12, upon first time entry into any Florida school, students who have previously attended any public or private school in Florida must have documentation of a physical exam. A child may be exempted from the requirement for a physical examination upon written request of the parent or guardian stating objection to such examination on religious grounds. The Collier County Health Department does not provide pre-entrance school physicals. Students new to Florida, who do not have health insurance or other means to obtain a physical, may be referred to the Ronald McDonald Caremobile for a free school-entry physical. Students who are scheduled for a physical on the CareMobile may be admitted to school. Social Security Information As a result of increased attention and concern regarding identity theft, the District School Board would like to clarify the procedures for obtaining a student’s social security number. Florida Statute 1008.386 “requires school districts to request a social security number for each student in grades PreK–Adult who enroll in school. However, a student is not required to provide his or her social security number as a condition for enrollment or graduation.” Refusal to provide a social security number will not be documented in the student’s file. The student’s identity may be verified by one of the following documents: • Original copy of the Social Security Card (if available). • Bank statements, insurance records or other similar documents that periodically

require verification and contain the student’s social security number. • A signed statement, by the parent, either submitted separately or included as part of

another district form that attests to the authenticity of the student’s social security number.

If a student does not provide a social security number, the school district should assign a number using the common method statewide. • First Two Digits For any student entering a Florida school district for the first time

who does not have a social security number, the first two digits will represent the district of initial entry into the Florida school system.

• Last Eight Digits The last eight digits are district-defined in such a way as to result in a unique student number within the district where the number is originally assigned.

If a student does not provide a social security number at the time of entry, but later provides a social security number, the district must update the Student Identification Number with a verified social security number.

School staff must not make copies of alien cards, social security cards, licenses, or passports from students or their parents when registering students. Parents may be asked

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to complete the social security information on the registration form, but they are not required to do so.

In order to be in compliance with the META Consent Decree for ESOL students, there will be no photocopies of the student’s and/or parent’s social security cards, alien cards, licenses, passports or similar documentation anywhere in the student’s cumulative file. No personally identifiable data of any kind shall be elicited, compiled or maintained as to any individual student’s immigration status. Other papers that happened to contain the student’s social security number on them, such as test results and reports that are in the student’s cumulative file, are not a concern. Proof of Age Per Florida statute, any student entering PK-12 shall show an original or certified copy of a birth certificate or other proof of age. The following are acceptable documents for evidence of date of birth: • Birth Certificate; (original or certified copy of birth certificate) • A certificate of baptism showing the date of birth and place of baptism of the child,

accompanied by an affidavit sworn to by the parents (Appendix D); • An insurance policy on the child’s life which has been in force for at least two years;

bona fide contemporary Bible record of the child’s birth accompaniedby an affidavit sworn to by the parent (Appendix D);

• A passport or certificate of arrival in the United States stating the age of the child; • A transcript or record of age shown in the child’s school record of at least four years

prior to application, stating date of birth. • An affidavit of age sworn to by the parent accompanied by a certificate of age signed

by a public health officer or private physician indicating that the physician has examined the child and believes that the age as stated in the affidavit is substantially correct. (Appendices, D, E) A homeless child, as defined in s.1003.21 shall be given temporary exemption from this section for 30 school days.

Notice The principal will refer cases of suspected document fraud (original birth

certificate, official transcript) to the Youth Relations Deputy from the Collier County Sheriff’s Office assigned to the school.

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Kindergarten

Florida Statute 1003.21 requires that a child be five (5) years old on or before September 1, 2007 in order to enroll in public kindergarten. (See Proof of Age).

Only one exception is made to the age requirement for entrance into kindergarten. The exception involves kindergarten students transferring from another state. Such transfer students may be admitted regardless of age, if two criteria are met:

• The transfer student must meet the entrance age requirements of the public schools of the state from which he/she is transferring.

• The parents or legal guardians of the child must have been legal residents of the state from which the child is transferring.

First Grade

Florida Statute 1003.21 requires satisfactory completion of kindergarten, in order for a child to be eligible to enter first grade. A child who has satisfactorily completed either public or private kindergarten may be admitted to first grade if he/she will be six years old on or before September 1. All students entering first grade other than those transferring from Florida public schools must provide documentation of birth date. (See Proof of Age.)

Children who have attended a private kindergarten may be admitted to first grade only upon presentation of a letter from the director of the private kindergarten indicating that the child has satisfactorily completed a kindergarten skill developmental program. An exception may be made regarding age requirements for first grade entrants. Students transferring from another state may be admitted to first grade, if the following three criteria are met: • The child has successfully completed kindergarten in the state from which he/she is

transferring. • The child meets the entrance age requirements of the public schools of the state from

which he/she is transferring. • The parent or legal guardian of the child was a legal resident of the state from which

the child is transferring.

Florida Statute 1003.21(1) (a) requires that any child who has attained the age of six years or who will attain the age of six years by February 1st, of the current year, attend school regularly throughout the school year.

Before admitting a child to the first grade who has attended a private kindergarten in Florida, the principal shall require evidence of date of birth as required by law. (See kindergarten enrollment procedures for acceptable proof of age.)

Students not meeting age requirements but who have satisfactorily completed the requirements for kindergarten in a private school from which the district school board accepts transfer in a manner similar to that applicable to other grades, shall progress according to the district’s student progression plan.

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High School: Regular Students, Students Over the Age of 16, or Emancipated Minors All high school transfer students must have an official transcript from the last school that they attended. An official transcript is a document that is sent directly from the administrator of the school where the credit is earned to the receiving school administrator. An unofficial transcript is one that is hand delivered by the student or parent, or is delivered to the designated school administrator in an open envelope, or on plain paper. For transfer students ages 16 or older, an official transcript from the last school attended must be received and reviewed by the school counselor prior to enrollment if there has been a significant gap of a semester or more in their high school enrollment history. For transfer students age 16 or older without a gap of a semester or more in their high school enrollment history, an official transcript from the last school attended must be received no later than the end of the first complete term after the enrollment of the student. If it is not received, the student will be withdrawn and referred to Adult Education subject to legal review. Students must be able to meet the graduation requirements by the school year of their 21st birthday (22 for ESE).Students who can’t meet the graduation requirements or who have significant gaps in their high school enrollment history may be referred to Adult Education. A student between the ages of sixteen (16) and twenty-one (21) may not enroll or withdraw themselves from general education without parental permission or guidance, unless they are an emancipated minor (as evidenced by legal documents). Per Florida Statute s.1003.21 a student who attains the age of 16 years is not subject to compulsory school attendance beyond the date upon which he or she attains that age, if the child files a formal declaration of intent to terminate school enrollment with the District School Board (See Appendix G). The student must meet with the Principal or designee for an exit interview before submitting an intent to terminate school enrollment. The declaration must acknowledge that terminating school enrollment is likely to reduce the student’s earning potential and must be signed by the child. The school district must notify the child’s parent or legal guardian of the child’s declaration of intent to terminate school enrollment. Per School Board policy 5112.01 (Appendix F), in order to provide reasonable consistency of maturity levels among students in the regular high school program, no person shall be permitted to attend the regular high school program beyond the school year during which they attain the age of twenty-one (21). • Persons who are eighteen (18) years old or older and who, by earning eight (8) credits

per academic year, cannot meet regular education graduation requirements, including grade point average (GPA), prior to the end of the school year during which they attain the age of twenty-one (21), shall not be permitted to register, enroll, or attend the regular high school program beyond the end of the academic year in which they attain the age of eighteen (18). Such persons shall be afforded an opportunity to

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pursue a high school diploma through the Adult High School or General Educational Development (GED) programs of the Collier County Public Schools.

• The provisions of this policy limiting enrollment of students between the ages of

eighteen (18) and twenty-one (21) years shall not be automatically applied to students served by the district’s Exceptional Student Education Programs for students with disabilities. The provisions of this policy may, however, serve as guidelines for Staffing/IEP Committees as the educational needs of students with disabilities are individually considered. The district will provide services to students with disabilities until the end of the semester in which they turn twenty-two (22).

• In order to protect the safety and welfare of younger students, principals may refuse enrollment in the regular high school education program to those persons who have had a history of disruptive behavior in the school setting, who have attained the age of eighteen (18) years, and who have previously dropped out of the regular high school program; and refer them to Adult Education. Such persons shall be afforded the opportunity to pursue a high school diploma through the Adult High School or General Educational Development (GED) programs of the Collier County Public Schools. The provisions of this paragraph shall not apply to students who are classified as Exceptional students.

High School Head of Guidance will review the academic standing of students 18 years old and older prior to and at the conclusion of Term 1, as well as, students without official transcripts.

Homeless Students (Policy 5111.01)

The McKinney-Vento Act defines homeless children and youth as individuals who lack a fixed, regular and adequate nighttime residence [Section 725(2)]. This includes: 1. Children and youth who are:

a. sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason (sometimes referred to as “doubled up”);

b. living in motels, hotels, trailer parks, or camping grounds due to the lack of alternative adequate accommodations;

c. living in emergency or transitional shelters d. abandoned in hospitals; e. awaiting foster care placement.

2. Children and youths who have a primary nighttime residence that is a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings.

3. Children and youth who are living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations, or similar settings.

4. Migratory children who qualify as homeless for the purposes of this because the children are living in circumstances described above.

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Also included are: 1. Homeless preschoolers. 2. Homeless unaccompanied youth, which includes youth who are not in the physical

custody of a parent or guardian [Section 725 (6)]. This would include youth living in runaway shelters, abandoned buildings, cars, on the streets, or in other inadequate housing; youth denied housing by their families (sometimes referred to as “throwaway” youth); and school-age unwed mothers, living in homes for unwed mothers, who have no other housing available.

If a youth’s living situation does not clearly fall into the situations described above, the LEA should refer to the McKinney-Vento definition of “fixed, regular, and adequate nighttime residence” and consider the relative permanence of the living arrangements. The Act [Section 722(g)(3)(C) and(E), Public Law 107-110] requires enrolling schools to: 1. Immediately enroll the homeless student, even if the student is unable to produce

records normally required for enrollment such as previous academic records, medical records, proof of residency, or other documentation.

2. Immediately contact the prior school the student attended to obtain relevant academic and other records.

3. Immediately refer the parent or guardian of the student or the unaccompanied youth to the local homeless liaison to assist in obtaining necessary immunizations, or medical and immunization records, if needed.

4. Provide a written explanation of its decision and the right to appeal if a student is sent to a school other than an eligible one requested by a parent or guardian or the unaccompanied youth.

Students with Expulsions and Arrests

• Disclosure at time of registration – Chapter 1006.07 of the Florida law requires that any student seeking admission to a public school in the State of Florida be required to provide information regarding expulsions, arrests which may have resulted in a formal charge, or any involvement with the Juvenile Justice System. This information is requested at the time of initial registration and indicated on the registration form.

Temporary Enrollment of Student for Testing Purposes Only Contact Exceptional Student Education (ESE) Department at 239-377-0084 for procedures.

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Part II: Transfer Students

Enrollment Students Entering from another School In-County

• Require the student to present a completed Withdrawal Form from the releasing school. The school may telephone the releasing school to determine if the student has properly withdrawn. If the student has not properly withdrawn, he/she should return to the releasing school to be properly withdrawn. (This applies more to secondary students than to elementary.)

• Request the student's cumulative folder from the releasing school. • Students entering from the Home Education Program must complete and return an

Intent to Withdraw from Home Education form to the Department of Student Services.

Students Entering from Out-of-County, Out-of-State or Out-of-Country

• Require the student to present a completed Withdrawal Form from the releasing school. The school may telephone the releasing school to determine if the student has properly withdrawn.

• High School students MUST provide an official transcript from previous school. • Request the student's cumulative folder from the releasing school.

Withdrawal

Students Transferring In-County

• Issue a copy of the completed standard Withdrawal Form for each student to hand carry to the receiving school.

• When requested by the receiving school, forward the student's cumulative folder directly to that school. Do not forward the student's cumulative folder until it is requested by the receiving school.

• When entire classes of students are promoted to another school within Collier County at the end of the school year, the principal of each transferring school or his designee shall personally transport a list of the students’ names and their respective cumulative folders to the appropriate receiving schools. A receipt for the cumulative folders from the receiving school should be obtained.

Students Transferring Out-of-County or Out-of-State

• It is recommended that a copy of the immunization certificate and school physical examination be given to parents of children transferring from Collier County Public Schools to another school system. This will help to facilitate the child's enrollment in the new system.

• Issue the standard Withdrawal Form when the parent notifies the school that the

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student is leaving or transferring to another school. • The transfer of student records shall be made immediately upon request by the parent

or receiving school. All reasonable effort shall be made to collect fines, but under no circumstances shall the transfer of a student's records be delayed or denied for failure to pay a fine or fee assessed by the school.

High School Students Withdrawing from School with a Dropout Withdrawal Code

If a secondary student has dropped out of school, he/she should be referred to the school counselor so that an Exit Interview (see Appendix I) and the Declaration of Intent to Terminate School Enrollment Form can be completed by the student and copied to the parent. (See Appendix G) Exit Interview forms should be placed with the students’ educational records. Note: W05 Code is for any student age 16 or older who leaves school voluntarily with no intention of returning. W15 A student may only be withdrawn from school due to nonattendance after all in sections 1003.26 and 1003.27, Florida Statutes, have been followed. Procedures for Checking Students Out of School during the School Day 1. When enrolling children in school, parents indicate contact information on the district

enrollment form. The contact information section of the enrollment form includes the name(s) of parent/guardian, other, and emergency contact (name/relationship), home and work telephone numbers for each person listed and whether each person is authorized to pick up the student, and whether each person has have legal custody of the child. This contact information is entered by the school on the TERMS screen panel S315.

2. At the beginning of each school year, an emergency contact form is sent home with students for parents to provide current emergency contact information, which is updated in TERMS.

3. Students leaving school during the school day must be signed out by an adult through

the office. a. The adult must be authorized to pick the student up from school according to

the contact information recorded in TERMS. b. Identification must be provided by the adult. c. If an emergency situation requires a parent to send a person to pick up their

child who is not listed in the emergency contact information, the school must receive permission in a form satisfactory to the principal from the parent to authorize this pick up.

The adult signs the student out of school by signing the log sheet maintained by the school.

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Part III: Students from Foreign Countries

VISA’s, I-20’s and Foreign Exchange Students

The District School Board of Collier County does not issue I-20 forms. Moreover, students who possess F-1 (academic) or M-1 (vocational) visas are not eligible for enrollment since they have received such status through other educational institutions or programs. Per Homeland Security s.214.2(7) Enrollment in a course of study prohibited – “An alien who is admitted as, or changes status to, a B-1 or B-2 non-immigrant status on or after April 12, 2002, or who files a request to extend the period of authorized stay in B-1 or B-2 non-immigrant status on or after such date, violates the conditions of his or her B-1 or B-2 status if the alien enrolls in a course of study.” Per district procedures 5114 – Foreign Exchange Students Foreign exchange program students, who possess J-1 visas, are eligible for enrollment for the duration of stay permitted by the visa or other United States Department of Regulations upon proof of approval by the appropriate sponsoring authority. Foreign exchange program students must:

A. have sufficient knowledge of the English language to participate in high school classes;

B. submit a transcript in English of the secondary school work prior to enrollment; C. have provided appropriate insurance coverage; D. be accepted by a host family in the zone of attendance; E. obtain prior written approval of the principal.

The host family will contact the guidance office at the home zoned high school to initiate the registration process. The following information must be provided:

A. Proof of residency – the host family must provide three (3) proofs that they reside in the school zone.

B. Immunization – the host family will obtain a Florida Immunization Certificate by taking the student’s immunization record to the Collier County Department of Health.

C. Physical – the host family will provide evidence of a physical exam within the twelve (12) months prior to starting school by obtaining a school physical form.

D. Student passport and J-1 Visa. All foreign exchange students must be enrolled and participating in a full course of study and a full day schedule; and comply with all District rules and regulations.

Note: Foreign exchange program students who have received a high school diploma from another country are not eligible to enroll in the District. Note: Foreign exchange program students enrolled in the District are not eligible to receive a high school diploma. Any credits earned will be transferred back to the student’s home country. However, class rings and yearbooks may be purchased on the same terms as they are by other students.

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Part IV: Appendix

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STUDENT ENROLLMENT Name of staff completing form_________ Date completed

THIS AREA FOR OFFICE USE ONLY SCHOOL NAME

CCPS STUDENT # ENTRY DATE GRADE TEACHER NAME FLORIDA ID #

Birth Verification (1-9)______ Health Exam Valid Immunization Certificate Valid Out-of-Zone Yes No

Bus #________________ Previous school records requested________

DIRECTIONS: Parent/Guardian please complete all areas and check appropriate boxes, sign and date

Student's Legal Name: Also known as (alias): Last First Middle

Residence Address Apt#

Mailing Address (if different than residence address) Apt #

City State Zip

City State Zip

Has your child attended a United States school for less than 3 full years? Yes No If yes, date entered in U.S. MM/DD/YY _____/_____/_____

Is your child a member of an active military family? Yes No

Is your child Hispanic or Latino? Yes No What is your child’s race? (mark all that apply) American Indian or Alaska Native Asian Black or African-American Native Hawaiian or Pacific Islander White

Sex: Date of Birth: Male Female MM/DD/YY _____/_____/_____

Place of Birth: City: State: Country of birth if other than U.S.:

Is a language other than English used in the home? Yes No If yes, what language? (Hm) Did the student have a first language other than English? Yes No If yes, what language? (Pl) Does the student most frequently speak a language other than English? Yes No If yes, what language? (Sl)

STUDENT Social Security # (optional):

In which language do you prefer to be contacted either in writing or by phone? (Cl) English Spanish Haitian/Creole

Does student live with parent? Yes No If yes and parents are not married: _____custody documentation ___restraining order If no: name of guardian _________________ ________________ relationship to student________________________ _____power of attorney provided _____ Statement of Acceptance of Responsibility form provided Is student in foster care placement? Yes No If yes, name of guardian_______________________________________ Is your family residing in any of the following situations? Sharing the housing of others due to loss of housing or economic hardship (Code B) Living in a motel or hotel due to loss of housing or economic hardship (Code E) Staying in a shelter _____Immokalee Friendship House ___St. Matthew’s House _____Providence House (Code A) Substandard house; without electricity, running water, health code violations, lack of cooking capabilities, etc. (Code D) Sleeping in a car, campground, park or public space (Code D)

17

CONTACT INFORMATION PARENT/GUARDIAN NAME (Please include address if different from student) Home Phone Work Phone Cell Phone Authorized

Pickup Legal Custody

Mother/Guardian: Email:

Yes No

Yes No

Father/Guardian: Email:

Yes No

Yes No

Other (Name/Relationship):

Yes No

Yes No

Emergency Contact (Name/Relationship):

Yes No

Yes No

Has student ever attended a Collier County public school? Yes No

Has student attended a Florida public school? Yes No

Last School/Preschool Attended – Name Withdrawal Date ______/______/_______ Address City State Zip Phone #

Was your child in any Exceptional Education program at his/her previous school, i.e., Speech, SLD, Gifted, EBD, etc.? Yes No

Was your child in an ELL program at his/her previous school? Yes No

Has your child ever been arrested resulting in a charge or juvenile justice action? Yes No If Yes, please direct parent to School Counselor

At this time, is your child under an expulsion or alternative placement order? Yes No If yes, please identify where (what school) and when (what dates) I certify that the above enrollment information is true and accurate to the best of my knowledge. ____________________________________ _________________________________ ____________________ __________ Printed Name of Parent/Guardian Signature Relationship Date

THE COLLIER COUNTY PUBLIC SCHOOL SYSTEM IS AN EQUAL ACCESS / EQUAL OPPORTUNITY INSTITUTION FOR EDUCATION AND EMPLOYMENT revised 03/01/2012

18

INSCRIPCION DEL ESTUDIANTName of staff completing form________ Date completed

ESTA AREA ES SOLAMENTE PARA EL USO DE LA ADMINISTRACION SCHOOL NAME CCPS STUDENT # ENTRY DATE GRADE TEACHER NAME FLORIDA ID #

Birth Verification (1-9)______ Health Exam Valid Immunization Certificate Valid Out-of-Zone Yes No

Bus #________________ Previous school records requested________

INSTRUCIONES: Padre/Encargado favor de completar todas las áreas, chequear las casillas apropiadas, firmar y poner la fecha

Nombre Legal del Estudiante: También conocido como (alias): Apellido Primer Nombre Segundo Nombre Dirección de la Residencia #de Apto.

Dirección Postal (si es diferente de la dirección residencial) # Apto

Cuidad Estado Código Postal

Cuidad Estado Código Postal

¿Ha estado su hijo asistiendo a una escuela en los Estados Unidos por menos de tres años completos? Sí No De ser sí, indique su fecha de entrada al país. _____/_____/_____

¿Es su hijo miembro de una familia militar activa? Sí No

¿Es su hijo hispano o Latino? Sí No ¿Cual es la raza de su hijo? (marque los que sean aplicables) Indígena de las Américas o de Alaska Asiática Negra o Africana-Americana Indígena de Hawái o de las Islas del Pacífico Blanca

Sexo: Fecha de Nacimiento: Masculino Femenino Mes/Día/Año _____/_____/_____

Lugar de Nacimiento: Cuidad: Estado: País de Nacimiento si no es Estados Unidos:

¿Se habla en el hogar un idioma que no sea el inglés? Sí No De ser sí, ¿qué idioma? (Hm) ¿Inicialmente, habló el estudiante un idioma que no era el inglés? Sí No De ser sí, ¿qué idioma? (Pl) ¿El idioma que el estudiante habla con más frecuencia es otro que no sea el inglés? Sí No De ser sí, ¿que idioma? (Sl)

# de Seguro Social del ESTUDIANTE (opcional):

¿En qué idioma desea usted ser contactado sea por escrito o por teléfono? (Cl) Inglés Español Criollo Haitiano

¿Vive el estudiante con algún padre? Sí No De ser sí, y los padres no están casados: _____Orden Judicial de Custodia de Menores ___ Orden de Protección/Restricción De ser no: nombre del encargado_____________________________ parentesco con el estudiante______________________ _____Carta Poder provista _____ Formulario de Declaración de Aceptación de Responsabilidad provisto ¿Está el estudiante viviendo en un hogar adoptivo provisional (foster care)? Sí No De ser sí, nombre del tutor legal___________ ¿Vive su familia en alguna de las siguientes situaciones? Compartiendo la vivienda de otros a causa de perdida de alojamiento o dificultades económicas (Code B) Viviendo en un motel u hotel a causa de pérdida de alojamiento o dificultades económicas (Code E) Alojamiento en un refugio ___Immokalee Friendship House ___St. Matthew’s House ___Providence House (Code A) Vivienda inadecuada; sin electricidad, sin agua, con infracciones del código de salud, sin cocina, etc. (Code D) Durmiendo dentro de un automóvil, en un campamento, parque o lugar público (Code D)

19

INFORMACION DE CONTACTO NOMBRE DEL PADRE/ENCARGADO (Favor de incluir la dirección si es diferente a la del estudiante) Teléfono Tel. Trabajo Tel. Celular Autorizado

para recoger Custodia Legal

Madre/Encargado: Correo Electronico

Sí No

Sí No

Padre/Encargado: Correo Electronico

Sí No

Sí No

Otro (Nombre/Parentesco):

Sí No

Sí No

Contacto en caso de emergencia (Nombre/Parentesco):

Sí No

Sí No

¿Asistió alguna vez a una escuela pública del Condado de Collier?

Sí No ¿Asistió alguna vez a una escuela de la Florida? Sí No

La última escuela/Pre-Escolar que asistió – Nombre Fecha de Salida _____/_____/_____ Dirección Cuidad Estado Código Postal #Teléfono

¿Estuvo su hijo en algún programa de Educación Excepcional en la escuela anterior, es decir, clase del habla, SLD, Dotado, EBD, etc.? Sí No

¿Estuvo su hijo en un programa de ELL en la escuela anterior? Sí No

¿Ha sido su hijo alguna vez arrestado resultando en una acusación o Acción de Justicia Juvenil? Sí No If (Sí) Yes, please direct parent to School Counselor

¿Está su hijo/a en estos momentos bajo una orden de expulsión o de ubicación alterna? Sí No De ser sí, favor de explicar dónde (qué escuela) y cuándo (fecha) Yo certifico que toda la información de inscripción más arriba descrita es verdadera y exacta según mi entender. ____________________________________ _________________________________ ____________________ __________ Nombre del Padre/Encargado (letra de molde) Firma Parentesco Fecha

EL SISTEMA DE LAS ESCUELAS PÚBLICAS DEL CONDADO DE COLLIER ES UNA INSTITUCION CON IGUALDAD DE ACCESO Y OPORTUNIDADES PARA LA EDUCACION Y EL EMPLEO revised 04/30/2010

20

FEY ENSKRIPSYON ELEV YO Non manb pèsonèl ki konplete fòm sa a

Dat fòm nan konplete

SEKSYON SA A SE POU OFISYEL YO SELMAN NON LEKOL LA CCPS STUDENT # ENTRY DATE GRADE TEACHER NAME FLORIDA ID #

Birth Verification (1-9)______ Health Exam Valid Immunization Certificate Valid Out-of-Zone Yes No

Bus #________________ Previous school records requested________

DIREKSYON: Paran/Responsab souple konplete tout pati nan fèy la epi tcheke kazye apwopriye yo, siyen epi mete dat.

Non Legal Elèv la: Epi yo konnen li sou non (alias): Siyati Non Non Mitan

Adrès kote li Rezide # Apt

Adrès li Resevwa Lèt (Si li diferan de adrès kote li rete a) # Apt

Vil Eta Kòd Postal

Vil Eta Kòd Postal

Eske pitit ou a te frekante yon lekòl nan peyi Etazini pandan mwens pase 3 ane an plen? Wi Non Si wi, bay li te antre nan peyi Etazini. MM/DD/YY _____/_____/_____

Eske pitit ou a se manb yon fanmi ki aktif nan sèvis militè? Wi Non

Eske pitit ou a se Ispanik oubyen Latino? Wi Non Se nan ki ras pitit ou a soti? (make tout sa ki aplike pou li) Endyen Ameriken Endyen oubyen Natif Alaska Azyatik Nwa oubyen Afriken-Ameriken Natif Hawaii oubyen Zile Pasifik Blan

Sèks: Dat Nesans: Mal Femèl MM/DD/YY _____/_____/_____

Kote li fèt: Vil: Eta: Peyi kote li fèt si se pa Ozetazini:

Èske yo pale yon lòt lang ki pa Anglè lakay la? Wi Non Si wi, se ki lang? (Hm) Èske elèv la te pale yon premye lang ki pa Anglè? Wi Non Si wi, se ki lang? (Pl) Èske elèv la pale yon lòt lang ki pa Anglè pi souvan? Wi Non Si wi, se ki lang? (Sl)

# Sekirite Sosyal ELEV LA (opsyonèl):

Nan ki lang ou prefere nou kontakte ou ke se swa pa ekri oubyen nan telefòn? (Cl) Anglè Espanyòl Kreyòl

21

ENFÒMASYON POU KONTAK NON PARAN/RESPONSAB LA (Tanpri enkli adrès ou si li diferan de pa elèv la)

Telefòn Lakay

Telefòn Travay

Telefòn Pòtab

Otorize pou vin Pran li

Gadyen Legal

Manman/Responsab:

Wi Non

Wi Non

Papa/Responsab:

Wi Non

Wi Non

Lòt Moun (Non/Relasyon):

Wi Non

Wi Non

Kontak Dijans (Non/Relasyon):

Wi Non

Wi Non

Eske elèv la te janm ale nan yon lekòl piblik Collier County? Wi Non

Eske elèv la te ale nan yon lekòl piblik nan Florida? Wi Non

Dènye Lekòl/Pre-eskolè li te Frekante – Non Dat li Soti ______/______/_______ Adrès Vil Eta Kòd Postal # Telefòn

Eske pitit ou a te patisipe nan nenpòt pwogram Edikasyon Eksepsyonèl nan lekòl avan li yo, i.e., Pale, SLD, Don, EBD, etc.? Wi Non

Eske pitit ou a te nan yon pwogram ELL nan lekòl li te frekante avan yo? Wi Non

Eske yo te arete pitit ou a akoz yon aksyon an jistis jivenil ki t’ap peze kont li? Wi Non Si Wi, tanpri transfere paran an bay Konseye Lekòl la

Nan moman nou ye la a, èske pitit ou a sou zòd pou yo mete li deyò lekòl la oubyen pou yo voye li nan plasman altènatif? Wi Non Si wi, tanpri idantifye ki kote (ki lekòl) ak kilè (ki dat) Mwen sètifye ke enfòmasyon sou enskripsyon ki pi wo a vrè e ekzak dapre sa mwen konnen. ____________________________________ _________________________________ ____________________ __________ Enprime Non Parant/Responsab la Siyati Relasyon Dat

SISTEM LEKOL PIBLIK COLLIER COUNTY SE ENSTITISYON KI BAY AKSE EGAL / OPOTINIT EGAL POU EDIKASYON AK TRAVAY revize 04/30/2010

22

Annual Student Emergency Information Card for School Year 2012-13 This card must be completed by parent/guardian and signed each school year

Please notify the school if any of the following information changes during the year

PLEASE COMPLETE IMPORTANT INFORMATION ON REVERSE SIDE

School: Teacher: Student ID #: Grade:

Name of Reviewing School Nurse: Date Reviewed: Actions:

Parent/Guardian- Please complete all areas below (print), Check appropriate boxes, sign, date, and return. Student's Legal Name: Last First Middle

Also known as (alias): Last First Middle

Sex Male Female Date of Birth: Month/Day/Year _____/_____/_____

Is your child covered by: __ Private health insurance __ Medicaid __ Healthy Kids/Kid Care __ No insurance

Does student live with parent? Yes No If no, name/relationship of guardian: ____________________________________________________________________________ Court-ordered custody document provided? Yes No Court ordered restraint order? Yes No

Student’s home phone:

Student’s Home Address: Apt# Student’s Mailing Address (if different than home address) Apt #

City State Zip City State Zip

Is this a new address? Yes No

Contact and Emergency Information (Attach additional page if necessary) Parent/Guardian Name (Please include address if

different from student) Home Phone

Work Phone

Cell phone or Pager

Authorized Pickup

Legal Custody

Mother/Guardian Name Address (If different) Email:

Yes No

Yes No

Father/Guardian Name Address (If different) Email:

Yes No

Yes No

Other (Name/Relationship Address (If different)

Yes No

Yes No

If parent/guardian cannot be reached please notify the person(s) below in case of an emergency. Emergency Contact (Name/Relationship)

Yes No

Yes No

Emergency Contact (Name/Relationship)

Yes No

Yes No

Please provide names of other children attending Collier County Public Schools:

Current District School Attending:

23

Annual Student Emergency Information Card for School Year 2012-13 This card must be completed by parent/guardian and signed each school year

Please notify the school if any of the following information changes during the year

Privacy Statement: The District School Board of Collier County (CCPS) provides for first aid and emergency response to illness and injury in public schools and provides health services to student in public schools in partnership with: Collier County Health Department (CCHD), NCH Healthcare System, Inc. (NCH), and the Ronald McDonald Care Mobile. The partners are required by law to maintain the privacy of your child’s protected health information. The District’s Notice of Privacy Practices describes how your child’s protected health information may be used, how the information is kept private and confidential, and explains the legal duties and practices relating to the protected health information. This Notice of Privacy Practices is available to you upon your request and is available at your child’s school. By signing this document, I understand and agree that information contained on this card may be shared with appropriate school staff and health care professionals according to the Health Insurance Portability and Accountability Act (HIPAA) on a need-to-know basis for the health and safety of my child.

Parent/Guardian Consent: By my signature below I accept responsibility to notify my child’s school of any changes of my home or business addresses and phone numbers in case of an emergency. I understand that EMS (911) will be called when there is an emergency requiring evaluation and/or transport of my child for medical treatment and I will assume responsibility for payment for EMS services. In case of an accident or illness for which immediate emergency treatment is not needed, but my child is unable to remain in school, I request that the school contact the parent(s)/guardian(s) named above. If unable to reach a parent or guardian, I request that one of the emergency contact person(s) listed on this card be contacted to pick up and/or care for my child until I can be reached. I also authorize Collier County School District, its designated employees, volunteers, and contracted agents, representatives, and personnel to provide health services, state mandated health screening and when necessary emergency care for my child and to exchange medical information as necessary to support the continuity of care for my child. If I do not want my child to receive these services, I will notify the school in writing of the specific services that are being declined. Furthermore, if my child is covered by Medicaid and receives health services under an IEP, I consent for the school district to bill Medicaid for those services provided. By signing this document, I certify that all the above emergency, health and medical information is true and accurate to the best of my knowledge. I also understand and agree that if I have identified that my child has a health or medical condition that may require some kind of assistance or management while he/she is in school, it is my responsibility to contact the school principal and/or school nurse; make them aware of the health or medical condition(s); and discuss a possible plan of care at school.

_________________________ _______________________ _________________ __________ Print Name of Parent/Guardian Signature Relationship Date

PLEASE COMPLETE IMPORTANT INFORMATION ON REVERSE SIDE

Student Health and Medical Information Name of Child’s Physician: Phone Number:

Name of Child’s Dentist: Phone Number:

Does your child have any health conditions that school staff members should be aware of? No Yes

If yes, please briefly describe the condition and any assistance needed: _______________________________________ ________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________ Does your child have any activity restrictions? No Yes If yes, please explain: ________________________________________________________________________________________________ Does your child have any allergies? No Yes - If yes, list ___________________________________________ Does the allergy require life saving medications? No Yes - What are the medications? __________________ _______________________________________________________________________________________________ Describe symptoms and treatment(s): ________________________________________________________________ _______________________________________________________________________________________________

Has a doctor told you your child has asthma? No Yes If yes, when was he/she diagnosed? _________________ Is medication for the asthma required at school? No Yes If yes, name of medication(s): ___________________ ________________________________________________________________________________________________

Does your child require medication at school on a regular basis? No Yes If yes, specify ____________________ ________________________________________________________________________________________________

(A completed and signed Medication Authorization form must be submitted to the school before medication may be administered.)

24

Tarjeta de Información Anual de Emergencia sobre el Estudiante para el Año Escolar 2012-13 Esta tarjeta debe ser completada y firmada por los padres/encargado cada año escolar

Favor de notificar a la escuela de su hijo si alguna de la información, cambia durante el año escolar

FAVOR DE COMPLETAR LA INFORMACION IMPORTANTE AL LADO OPUESTO

Escuela: Maestro: # ID del Estudiante: Grado:

Enfermera de Revisión de la Escuela: Fecha de Revisión: Acción:

Padres/Encargado- Favor de completar todo (letra de molde), marcar las casillas apropiadas, firmar con fecha, y devolverla a la escuela. Apellido Legal del Estudiante: Nombre: Segundo Nombre

También conocido como (alias): Apellido Nombre Segundo Nombre

Sexo M F Fecha de Nacimiento: Mes/Día/Año _____/_____/_____

¿Esta su hijo cubierto por?: __ Seguro de Salud Privado __ Medicaid __ Healthy Kids/Kid Care __ No tiene seguro

¿Vive el estudiante con sus padres? Sí No De ser no, nombre/parentesco del encargado: ____________________________________________________________________________ ¿Proveo la orden de custodia? Sí No ¿La orden de restricción? Sí No

# de teléfono del estudiante:

Dirección donde reside el estudiante: # Apt Dirección Postal del Estudiante (si es diferente al lugar donde reside) # Apt

Ciudad Estado Código Postal Ciudad Estado Código Postal

¿Es esta una nueva dirección? Sí No

Contactos e Información para Caso de Emergencia (Si fuera necesario puede agregar otra hoja) Nombre del Padre/Encargado (Incluya la dirección si es

diferente al lugar donde reside el estudiante) # Tel. # de Trabajo Celular Autorizado

para recoger al estudiante

Custodia Legal

Nombre de la Madre/ Encargada Dirección, si es diferente

Sí No

Sí No

Nombre del Padre/ Encargado Dirección, si es diferente

Sí No

Sí No

Otro (Nombre/ Parentesco) Dirección, si es diferente

Sí No

Sí No

En caso de emergencia: Si los padres/encargado no pueden ser localizados, notifique a las personas más abajo listadas. Contacto de Emergencia (Nombre/ Parentesco)

Sí No

Sí No

Contacto de Emergencia (Nombre/ Parentesco)

Sí No

Sí No

Favor de proveer los nombres de otros hijos que asisten a las Escuelas Públicas del Condado de Collier

Nombre de la escuela del Distrito a la que asiste actualmente:

25

Tarjeta de Información Anual de Emergencia sobre el Estudiante para el Año Escolar 2012-13

Esta tarjeta debe ser completada y firmada por los padres/encargado cada año escolar Favor de notificar a la escuela de su hijo si alguna de la información, cambia durante el año escolar

Declaración de Privacidad: La Junta del Distrito Escolar del Condado de Collier (CPS) provee primeros auxilios y responde a emergencias de lesiones y enfermedades en las Escuelas Públicas y provee servicios de salud a estudiantes en sociedad con el Departamento de Salud del Condado de Collier (CCHD), Sistema de Cuidado de Salud NCH, Inc. y el personal de cuidado móvil Ronald McDonald. A esta sociedad se le exige bajo la Ley mantener la privacidad de información protegida sobre la salud de su hijo/a. La Notificación del Distrito sobre las Prácticas de Privacidad le informa a usted como la protección de información de salud de su hijo/a puede ser utilizada, como la información es mantenida privada y confidencial y explica los deberes y las prácticas legales relacionados a la información protegida de salud. Esta notificación sobre las prácticas de privacidad, está a su disposición por petición suya y está disponible en la escuela de su hijo/a. Al firmar este documento, yo reconozco y estoy de acuerdo que la información contenida en esta tarjeta puede ser compartida con el personal escolar apropiado, con otros profesionales de cuidado de salud de acuerdo con la Ley de Health Insurance Portability and Accounting Act (HIPPA), basado en la necesidad de conocer sobre la salud y seguridad de mi hijo/a. Consentimiento de Padres/encargado: Por mi firma registrada más abajo, yo acepto la responsabilidad de notificar a la escuela de mi hijo/a de cualquier cambio en la dirección o teléfono de mi casa o lugar de trabajo en caso de que ocurra alguna emergencia. Yo comprendo que el EMS (911) será avisado cuando haya una emergencia, la cual requiere evaluación o transporte a mi hijo/a para tratamiento médico y que yo asumiré la responsabilidad de pagar por los servicios de EMS En caso de un accidente o enfermedad, donde tratamiento de emergencia inmediata no es necesaria, pero mi hijo/a no puede permanecer en la escuela, yo solicito que la escuela contacte a los padres/encargado nombrados más arriba. De ser imposible localizar a los padres/ encargado solicito que una de las personas de contacto listado en la tarjeta sea contactado para recoger o cuidar a mi hijo/a, hasta que yo pueda ser localizado. También autorizo al Distrito Escolar del Condado de Collier, a sus empleados designados, voluntarios y agentes contratados, representativos y personas para proveer cuidado de salud é investigaciones de salud por mandato del estado y cuando sea necesario, cuidado de emergencia para mi hijo/a y de intercambiar información médica como sea necesaria para apoyar el cuidado continuo de mi hijo/a. Además si mi hijo/a está cubierto por Medicaid y recibe servicios de Salud bajo el IEP, yo autorizo al Distrito Escolar que la cuenta sea enviada a Medicaid por los servicios prestados. Al firmar este documento, certifico que toda la información médica de salud y emergencia es verdadera y exacta según mi entender y también reconozco que he identificado que mi hijo/a tiene una condición médica o de salud que pudiera requerir algún tipo de asistencia o supervisión mientras que él/ ella asiste a la escuela y que es mi responsabilidad contactar al Director/a de la escuela y a la enfermera de la escuela para que ellos estén consciente de la condición médica o de salud de mi hijo/a y discutir un posible plan de cuidado en la escuela.

_________________________ _______________________ _________________ __________ Nombre del Padre/Encargado Firma Parentesco Fecha

FAVOR DE COMPLETAR LA INFORMACION IMPORTANTE AL LADO OPUESTO

Información Médica y de Salud del Estudiante Nombre del Doctor del Estudiante: # Teléfono:

Nombre del Dentista del Estudiante: # Teléfono:

¿Tiene su hijo alguna condición de salud del cual el personal escolar deba percatarse? No Sí

Favor de describir dicha condición y el tipo de asistencia requerida: _________________________________________ ________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________ ¿Tiene su hijo alguna restricción en alguna actividad? No Sí De ser sí, favor de explicarla: ________________________________________________________________________________________________ ¿Tiene su hijo alguna alergia? No Sí – De ser sí, lístela ___________________________________________ ¿Requiere la alergia medicamentos de salvamento? No Sí - ¿Qué clase de medicamento?_______________ _______________________________________________________________________________________________ Describa los síntomas y tratamientos: _________________________________________________________________ _______________________________________________________________________________________________

¿Le ha dicho el doctor que su hijo tiene asma? No Sí De ser sí, ¿Cuando fue diagnosticado? ________________ ¿Requiere el medicamento para asma en la escuela? No Sí De ser sí, ¿Cuales son los medicamentos? ________ ________________________________________________________________________________________________

¿Su hijo requiere medicamentos en la escuela con regularidad? No Sí De ser sí, cuales son estos? ___________ ________________________________________________________________________________________________

(Un formulario de Autorización Médica, completado y firmado, debe ser presentado a la escuela antes de poderle administrar medicamentos.)

26

Kat pou Bay Enfòmasyon Anyèl pou si elèv yo ta gen yon Ka dijans pou ane Lekòl 2012-13 Paran/responsab elèv yo dwe konplte epi siyen kat sa a chak ane lekòl

Tanpri fè lekòl la konnen si genyen nenpòt nan enfòmasyon sa yo ki chanje nan kouran ane a

Lekòl: Pwofesè: # ID Elèv la: Klas:

Non Enfimyè nan Lekòl la ki Revize Fòm nan: Dat yo Revize li: Aksyon:

Paran/Responsab - Tanpri konplete tout pati ki pi ba yo (enprime), tcheke kazye ki apwopriye yo, siyen, date, and Non Legal Elèv la: Non Fanmi li Non li Non Mitan li

Yo konnen li tou sou non (alias): Non Fanmi li

Non li Non Mitan

Sèks Mal Femèl Dat Nesans: Mwa/Jou/Ane _____/_____/_____

Eske pitit ou a genyen: __ Asirans sante prive __ Medicaid __ Healthy Kids/Kid Care __ Pa gen asirans

Eske elèv la abite avèk paran li? Wi Non Si non, bay non/relasyo responsab li a: ____________________________________________________________________________ Yo bay dokiman jijman tribunal li? Wi Non Yo bay dokiman jijman tribunal pou restren? Wi Non

Nimewo telefòn lakay elèv la:

Adrès Kay Elèv la: #Apt

Adrès pou Voye Lèt Bay Elèv la (si li diferan de adrès kay li)

#Apt

Vil Eta Kòd Postal

Vil Eta Kòd Postal

Eske sa a se yon nouvo adrès? Wi Non

Enfòmasyon pou Kontak ak Ka Ijan (Ajoute yon lòt paj pou mete plis enfòmasyon si se nesesè) Non Paran/Responsab (Tanpri enkli adrès ou si li

diferan ak pa elèv la) Telefòn Lakay

Telefòn Travay

Tel. Pòtab ou Pager

Otorize pou vin Chèche li

Respons-ab Legal

Non Manman/Responsab Adrès (si li diferan)

Wi Non

Wi Non

Non Papa/Responsab Adrès (si li diferan)

Wi Non

Wi Non

Lòt Moun (Non/Relasyon Adrès (si li diferan)

Wi Non

Wi Non

Si nou pa ka jwenn paran/responsab yo tanpri avèti moun ki pi ba a (yo) an ka k eta genyen yon ka ijan. Kontak pou Ka Ijan (Non/Relasyon)

Wi Non

Wi Non

Kontak pou Ka Ijan (Non/Relasyon)

Wi Non

Wi Non

Tanpri ba nou non lòt timoun ou genyen ki ap frekante Lekòl Piblik Collier County yo:

Distri Lekòl li ap Frekante Koulye a:

27

Kat pou Bay Enfòmasyon Anyèl pou si elèv yo ta gen yon Ka dijans pou ane Lekòl 2012-13 Paran/responsab elèv yo dwe konplte epi siyen kat sa a chak ane lekòl

Tanpri fè lekòl la konnen si genyen nenpòt nan enfòmasyon sa yo ki chanje nan kouran ane a

Deklarasyon sou Konfidansyalite: Konsèy Administrasyon Distri Lekòl Collier County (CCPS) ap bay premye swen epi ap reponn ak ka ijans lè gen elèv ki malad oubyen ki blese nan lekòl piblik yo an asosyasyon avèk; Depatman Sante Collier County (CCHD), Sistèm Swen Sante NCH, Inc. (NCH), ak Klinik Medikal Mobil Ronald McDonald. La lwa ekzije pou asosye sa yo kenbe epi pwoteje enfòmasyon pitit ou a an sekrè. Avi sou Pratik Konfidansyalite Distri a ap eksplike kijan yo dwe itilize enfòmasyon sou sante pitit ou a ki dwe pwoteje, kijan yo dwe kenbe enfòmasyon sa a an prive e konfidansyèl, epi li eksplike dwa ak devwa legal ansanm ak pratik ki gen rapò ak enfòmasyon sante pwoteje yo. Avi sou Pratik Konfidansyalite sa a disponib nan lekòl pitit ou a pou si ou ta bezwen gade sa ki ladan. Lè mwen siyen dokiman sa a, mwen konprann e mwen dakò ke yo ka pataje enfòmasyon ki nan kat sa a avèk manb pèsonèl lekòl ki apwopriye yo asanm ak lòt pwofesyonèl swen sante an akò ak Atik sou Responsabilite ak Pòtabilite Asirans Sante yo (HIPPA) si yo bezwen li pou sante ak sekirite pitit mwen an. Konsantman Paran/Responsab: Avèk siyati mwen poze anba fòm sa a, mwen aksepte responsabilite pou avize lekòl pitit mwen an si gen nenpòt chanjman ki fèt nan adrès ak nimewo telefòn lakay mwen ak travay mwen pou si ta gen yon ka ijans ki. Mwen konprann ke yo ap rele EMS (911) lè gen yon pwoblèm dijans ki ekzije pou yo transpòte pitit mwen an nan lopital pou al sibi tretman medikal epi mwen pral asime responsabilite mwen pou’m peye sèvis EMS yo. An ka aksidan oubyen maladi kote yo pap bezwen ba li tretman imedyatman, men kote pitit mwen an pap kapab rete lekòl la, mwen ap mande pou lekòl la kontakte non paran/responsab ki pi wo yo. Si yo pa kapab antre an kontak ak yon paran ou responsab, mwen ap mande pou yo kontakte youn nan non moun nou mete nan kat la pou ka dijans yo pou vin chèche timoun nan ak/oubyen pou vin okipe li pou jiskaske yo kapab kontakte mwen. Mwen otorize tou pou Distri Lekòl Collier County a, anplwaye yo dezinye, volontè ak ajan ki sou kontra yo, reprezantan ak manb pèsonèl founi sèvis sante, ekzamen sante preliminè ke eta a mandate epi lè sa nesesè pou sipòte ke yo kontinye pran swen pitit mwen an. Si mwen pa vle pou pitit mwen an resevwa sèvis sa yo, mwen ap fè lekòl la konnen sa pa ekri e mwen ap espesifye ki sèvis mwen refize yo. Plis ankò, si pitit mwen an genyen Medicaid epi li ap resevwa sèvis sante anba pwogram IEP li a, mwen konsanti pou distri lekòl la voye bòdwo peyman bay Medicaid pou sèvis yo bay yo. Lè mwen siyen dokiman sa a, mwen sètifye ke tout enfòmasyon ijans ki pi wo yo, enfòmasyon sante ak medikal yo vre e ekzak swivan sa mwen konnen. Mwen konprann tou e mwen dakò ke si mwen idantifye ke pitit mwen an gen yon kondisyon sante oubyen medikal ki kapab ekzije kèk asistans ou jesyon pandan ke yo lekòl la, se responsabilite pa mwen pou kontakte direktè lekòl la ak/oubyen enfimyè lekòl la; pou eksplike yo kondisyon sante oubyen medikal yo e diskite sou yon plan posib pou ba yo swen nan lekòl la. _________________________ _______________________ _________________ __________ Enprime Non Paran/Responsab la Siyati Relasyon Dat

TANPRI ALE KONPLETE ENFÒMASYON ENPÒTAN KI NAN DO FÒM NAN

Enfòmasyon sou Sante ak Enfòmasyon Medikal Elèv la Non Doktè Timoun nan: Nimewo Telefòn li:

Non Dantis Timoun nan: Nimewo Telefòn li:

Eske pitit ou a genyen kèk pwoblèm sante ke manb pèsonèl lekòl la dwe konnen? Non Wi

Si wi, tanpri dekri rapidman kondisyon pitit ou a epi di nou ki asistans li ap bezwen: ______________________________ ________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________ Eske pitit ou a gen kèk restriksyon pou pa patisipe nan kèk aktivite? Non Wi Si wi, tanpri eksplike nou: ________________________________________________________________________________________________ Eske pitit ou a soufri avèk kèk alèji? Non Wi – Si wi, ba nou lis la ______________________________________ Eske alèji li yo ekzije pou li pran medikaman pou sove vi li? Non Wi – Ki medikaman? ____________________ _______________________________________________________________________________________________ Dekri sentòm li yo ak tretman li bezwen: _______________________________________________________________ _______________________________________________________________________________________________

Eske yon doktè di w ke pitit ou a genyen azma? Non Wi Si wi, kilè yo te dekouvri sa? _____________________ Eske yo ekzije pou li pran medikaman pou azma yo nan lekòl la? Non Wi Si wi, bay non medikaman yo an(yo): ________________________________________________________________________________________________

Eske yo ekzije pou pitit ou a pran medikaman nan lekòl la yon fason regilye? Non Wi Si wi, espesifye _________ ________________________________________________________________________________________________

(Fòk ou konplete epi siyen yon fòm Otorizasyon pou bay Medikaman an epi soumèt li bay la avan pou yo ba li medikaman yo.)

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Appendix C

STATEMENT OF ACCEPTANCE OF LIABILITY AND RESPONSIBILITY FOR SCHOOL AGE CHILDREN

WHEREAS, F. S., 1003.21 requires regular school attendance of all children between the

ages of six and sixteen years, and WHEREAS, F. S., 1003.24 requires that each parent of a child within the compulsory

attendance age shall be responsible for such child's school attendance as required by law, and WHEREAS, F. S., 741.24 provides that specified entitles, including school boards, are

entitled to recover damages in an appropriate action at law in an amount not to exceed one thousand dollars ($1,000) in a court of competent jurisdiction from the parents of any minor under the age of eighteen years, living with the parents, who shall willfully or maliciously destroy property, real, personal or mixed, belonging to such school board, and

WHEREAS, the School Board of Collier County, Florida demands and requires that the above referred to provisions of Florida law be recognized and complied with by all those individuals who fall within the terms and conditions as set forth therein,

NOW THEREFORE, be it understood and agreed upon by and between the parties appearing as signatories: 1. That this statement is made to induce the School Board of Collier County to accept the

following named child as a student in the Collier County Public Schools, 2. That they agree to abide by and be bound to the Laws of the State of Florida, and in particular,

those laws enumerated herein, 3. That the individual signatory(ies) shall accept and agree to be bound , 4. That ______________________________________, age _____ is presently Name of Child

residing with the supervisory adult(s) in Collier County, Florida and desires entrance into the Collier County Public Schools,

5. That the supervisory adult's(s') relationship to said child shall be that of parent or guardian of said child,

6. That said supervisory adult(s) shall be responsible for the health, education, welfare and liability of the said child vis-a-vis the child's relationship with the Collier County Public Schools,

7. That I(We) have carefully examined the provisions contained herein and have signed this agreement after careful consideration and willful intent to be bound thereto.

IT IS AGREED UPON AND SIGNED this day of , 20 Parent or Guardian Supervisory Adult Parent or Guardian Supervisory Adult

STATE OF FLORIDA COUNTY OF COLLIER

The foregoing instrument was acknowledged before me this day of , 20 , by

Notary Public State of Florida My Commission Expires:

COLLIER COUNTY PUBLIC SCHOOLS IS AN EQUAL ACCESS/EQUAL OPPORTUNITY INSTITUTION FOR EDUCATION AND EMPLOYMENT

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DECLARACION ACEPTANDO COMPROMISO Y RESPONSABILIDAD HACIA NIÑOS EN EDAD ESCOLAR

CONSIDERANDO QUE, F. S., 1003.21 dispone de una asistencia regular a la escuela de todos los

niños entre los seis y los diez y seis aos de edad y, CONSIDERANDO QUE, F. S., 1003.24 dispone que cada padre o madre de un niño/a dentro de la

edad de asistencia obligatoria sea responsable de la asistencia a la escuela de ese niño/a como lo requiere la ley y,

CONSIDERANDO QUE, F. S., 741.24 estipula que personas juridicas específicas incluyendo consejos escolares, están autorizadas para obtener daños y perjuicios de los padres de cualquier niño/a menor de 18 años viviendo con los padres, por medio de una apropiada demanda legal, que haya voluntariamente y maliciosamente destruído propiedad, real, personal o ambas, perteneciendo al consejo escolar, en una cantidad que no exceda mil dólares, en un tribunal de juridicción competente y,

CONSIDERANDO QUE, el Consejo Escolar del Condado de Collier, Florida exige y dispone que lo anterior mencionado como previsto por la ley de Florida sea reconocido y cumplido por todas las personas que están dentro de los términos y condiciones como ha sido expuesto aquí,

POR CONSIGUIENTE, debe ser comprendido y aceptado por y entre las partes que aparecen como firmantes: 1. Que esta declaración se ha hecho para inducir al Consejo Escolar del Condado de Collier a aceptar

al ya nombrado niño/a como estudiante en las Escuelas Públicas del Condado de Collier, 2. Que están de acuerdo en acatar y someterse a las leyes del Estado de Florida, en particular a las

leyes enumeradas aquí, 3. Que la(s) persona(s) firmante(s) aceptará(n) y acatará(n) la definición de padres como se encuentra

en los Estatutos de Florida 228.041 (11), aunque este estatuto sea cambiado o permanezca igual, 4. Que _______________________________, edad ______________ actualmente reside Nombre del niño/a con el (los) adulto(s) de supervisión en el Condado de Collier, Florida y desea matricularse en las

Escuelas Públicas del Condado de Collier, 5. Que la relación de el (los) adulto(s) de supervisión con el niño/a será(n) la de padres o apoderado(s)

del mencionado niño/a, 6. Que el (los) adulto(s) de supervisión será(n) responsable(s) por la salud, educación, bienestar y

obligaciones hacia el niño/a mencionado con respecto a la relación del niño/a con las Escuelas Públicas del Condado de Collier,

7. Que yo (nostros) he (hemos) examinado cuidadosamente las provisiones que se encuentran en este documento y he (hemos) firmado este acuerdo despues de cuidadosas consideraciones y con el deliberado propósito de cumplir con esto.

SE HA ACORDADO Y FIRMADO EL de , 20 . Padres o apoderados Adulto de supervisión Padres o apoderados Adulto de supervisión

ESTADO DE FLORIDA CONDADO DE COLLIER

Lo anteriormente dicho ha sido afirmado en mi presencia el de , 20 por

Notario público State of Florida Mi comisión expira:

EL SISTEMA DE ESCUELAS PÚBLICAS DEL CONDADO COLLIER TIENE ACCESO DE IGUALDAD/ES UNA INSTITUCIÓN DEL IGUAL OPORTUNIDAD PARA EDUCACIÓN Y EMPLEO

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DEKLARASYON POU PRAN AN CHAJ AK AKSEPTE RESPONSABILITE TIMOUN KI NAN LAJ POU LEKÒL YO

LÈ’N KONSIDERE KE, F. S., 1003.21 ekzije pou tout timoun ki nan laj sis pou rive sèz an ale lekòl

regilyèman, epi

LÈ’N KONSIDERE KE, F. S., 1003.24 ekzije pou chak paran ki gen yon timoun ki nan laj obligatwa pou ale lekòl dwe asime responsabilite pou fè timoun sa a al chita sou ban lekòl jan ke la lwa ekzije sa, epi

LÈ’N KONSIDERE KE, F. S., 741.24 bay pou ke antite li espesifye yo, tankou konsèy administrasyon lekòl yo, gen libète pou repare domaj nan yon aksyon apwopriye ki ekzije yon depans ki pa depase mil dola ($1,000) e ki ap debat devan yon tribinal jistis konpetan pou paran nenpòt timoun ki poko rive nan laj 18 ane, ki ap viv avèk paran yo, ki pral detwi yon fason delibere osnon yon fason ki pa janti pwopriyete, byen, zafè pèsonèl ou ki pa pèsonèl, ki anba kontwòl konsèy administrasyon lekòl la, epi

LÈ’N KONSIDERE KE, Konsèy Administrasyon Lekòl Collier County, Florid la ekzije epi rekòmande pou ke tout moun ki tonbe anba tèm ak kondisyon sila yo rekonèt ak respekte atik lwa Florida ki pi wo yo,

PA KONSEKAN, pati ki siyen lwa sa a konprann e mete yo dakò sou sijè sa yo:

1. Ke deklarasyon sa a fèt pou entwodwi Konsèy Administrasyon Lekòl Collier County a pou aksepte non timoun ki pi ba a kòm elèv ki frekante Lekòl Piblik Collier County yo,

2. Ke yo dakò pou obeyi epi respekte Lwa Eta Florida yo, e an partikilye, lwa yo enimere yo, 3. Ke moun ki siyen yo dwe aksepte epi dakò pou respekte, 4. Ke ____________________________________, laj ___________ rezide nan Collier County,

Florida sou Non Timoun nan sipèvizyon yon granmoun, e li deside pou li antre nan Lekòl Piblik Collier County yo,

5. Ke granmoun ki ap sipèvize timoun sa a dwe reprezante yon paran oubyen yon responsab legal pou li, 6. Ke granmoun ki responsab sipèvizyon timoun sa a dwe okipe zafè sante, edikasyon, byenèt ak

pwoteksyon timoun sa a vizavi relasyon li ap antreprann avèk Lekòl Piblik Collier County yo, 7. Ke mwen (nou) ekzamine avèk swen ekzijans ki figire pi wo yo epi siyen akò sa a aprè anpil

konsiderasyon e pran angajman fèm pou obeyi règleman yo.

TOUT MOUN DAKO AK REGLEMAN SA YO E SIYEN YO nan jou mwa , 20 .

Paran oubyen Responsab Granmoun ki ap Sipèvize li

Paran oubyen Responsab Granmoun ki ap Sipèvize li

STATE OF FLORIDA COUNTY OF COLLIER

The foregoing instrument was acknowledged before me this day of , 20 , by

Notary Public

State of Florida My Commission Expires:

LEKOL PIBLIK COLLIER COUNTY YO SE YON ENSTITISYON KI BAY AKSE EGAL/OPOTINITE EGAL POU EDIKASYON AK TRAVAY

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Appendix D

SWORN STATEMENT VERIFYING BIRTHDATE

STATE OF FLORIDA

COUNTY OF COLLIER

Before me this day personally appeared ____________________________________________

Parent's Name who, being first duly sworn, deposes and says: 1. The affiant is the parent of ___________________________________________________

Child's Name 2. ____________________________________ was born on __________________________

Child's Name Birth Date

_______________________________ Parent's Signature

Sworn to and subscribed before me this ________ day of _________________, 20 .

___________________________ Notary Public

State of Florida My Commission Expires:____________

CCPS Fm # 10031

COLLIER COUNTY PUBLIC SCHOOLS IS AN EQUAL ACCESS/EQUAL OPPORTUNITY INSTITUTION FOR EDUCATION AND EMPLOYMENT

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Appendix E

CERTIFICATE OF AGE NAME OF CHILD ___________________________________________________________ DATE OF BIRTH SWORN TO BY PARENT: _______________________________________________________

(Month) (Day) (Year) I have examined the above-named child and believe that the age of the child as stated in the parent's affidavit is substantially correct.

___________________________________ SIGNATURE OF PHYSICIAN

___________________________________ DATE OF EXAMINATION

NOTE TO PHYSICIAN OR PUBLIC HEALTH OFFICER Any student entering the public school system must show acceptable evidence of date of birth. In the absence of a birth certificate, Florida law allows the following: "an affidavit of age sworn to by the parent, accompanied by a certificate of age signed by a public health officer or private physician indicating that the physician has examined the child and believes that the age as stated in the affidavit is substantially correct."

COLLIER COUNTY PUBLIC SCHOOLS IS AN EQUAL ACCESS/EQUAL OPPORTUNITY INSTITUTION FOR EDUCATION AND EMPLOYMENT

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Appendix F

The School Board of Collier County

Bylaws & Policies

5112.01 - MAXIMUM AGE FOR PARTICIPATION IN THE REGULAR HIGH SCHOOL PROGRAM

In order to provide reasonable consistency of maturity levels among students in the regular high school program, no person shall be permitted to attend the regular high school program after attaining the age of twenty-one (21). Those who attain the age of twenty-one (21) during a school year may complete that school year. Persons who are eighteen (18) years old or older and who, by earning eight (8) credits per academic year, cannot meet graduation requirements, including grade point average (GPA), prior to the end of the school year during which they attain the age of twenty-one (21), shall not be permitted to attend the regular high school program beyond the end of the academic year in which they attain the age of eighteen (18). Such persons shall be afforded an opportunity to pursue a high school diploma through the Adult High School or General Educational Development (GED) programs of the District. The provisions of this paragraph limiting enrollment of students between the ages of eighteen (18) and twenty-one (21) years shall not be automatically applied to students served by the District’s Exceptional Student Education Programs for students with disabilities. The provisions of this paragraph may, however, serve as guidelines for Staffing/IEP Committees as the educational needs of students with disabilities are individually considered. The District will provide services to students with disabilities until the end of the semester in which they turn twenty-two (22).

In order to protect the safety and welfare of younger students, principals may refuse enrollment in the regular high school program of those persons who have had a history of disruptive behavior in the school setting, who have attained the age of eighteen (18) years, and who have previously dropped out of the regular high school program. Such persons shall be afforded the opportunity to pursue a high school diploma through the Adult High School or General Educational Development (GED) programs of the District. The provisions of this paragraph shall not apply to students who are classified as exceptional students.

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Appendix G

THE DISTRICT SCHOOL BOARD OF COLLIER COUNTY DEPARTMENT OF STUDENT SERVICES

5775 Osceola Trail, Naples, Florida 34109 Phone: 239-377-0505

DECLARATION OF INTENT TO TERMINATE SCHOOL ENROLLMENT

Student Name: Last, First, Middle Date of Birth I.D. # Address: Street City Zip Telephone Number School Grade School Grade _________________________________________________________________________________________ Name/Title Witness I am sixteen (16) years of age or older and I intend to terminate my enrollment as a regular student in the District School Board of Collier County. • I understand that I am likely to reduce my lifetime earning potential if I leave school prior to

graduation. • I understand that I will be reported to the Department of Highway Safety and Motor Vehicles that will

lead to the suspension of my driver’s license or prevent my obtaining a driver’s license. • I understand that I will be reported to the Department of Children & Families and that, if my family is

receiving financial assistance, the amount may be reduced. _________________________________ _________________________________ Signature of Student (required) Signature of Parent/Guardian* *if unavailable, notify ____________________________________ Date Parent Notification of Student’s Declaration of Intent to Terminate School Enrollment Person notifying parent:_________________ Date of Notification:______________ Method of Notification: Conference Telephone Letter

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LA JUNTA DEL DISTRITO ESOLAR DEL CONDADO COLLIER DEPARTAMENTO DE SERVICIO AL ESTUDIANTE

5775 Osceola Trail, Naples, Florida 34109 Teléfono: 239-377-0505

DECLARACION SOBRE EL PROPOSITO DE TERMINAR LA INSCRIPCION EN LA ESCUELA

Nombre del Estudiante: Fecha de Nacimiento I.D. # Dirección: Ciudad Código Postal Número de Teléfono Escuela Grado _________________________________________________________________________________________ Nombre/Título Testigo Tengo 16 años de edad ó mayor y es mi intención de dar por terminada mi inscripción ómatrícula como estudiante regular en la Junta Escolar del Condado Collier. • Yo entiendo que si yo dejo la escuela antes de graduarme, ésto posiblemente reduzca mi potencial de

ganancias monetarias de por vida. • Yo entiendo que seré reportado al Departamento de Seguridad de Carreteras y Vehículo Motorizado

y que ésto llevará a la suspensión de mi licencia de conducir, ó impedirá mi obtención de dicha licencia.

• Yo entiendo que seré reportado al Departamento de Niños y Familia y que, si mi familia estuviera recibiendo ayuda financiera, la cantidad de dicha ayuda pudiera ser reducida.

_________________________________ _________________________________ Firma del Estudiante (requerida) Firma del Padre/encargafo* *Si no está disponible, favor de notificalo ____________________________________ Fecha Notificación al Padre/encargado sobre el Propósito del Estudiante de dar por Termimada su Inscripción ó Matrícula en la Escuela. Persona que notifica a los Padres/encargado:_________________ Fecha de la notificación:______________ Método de Notificación: Conferencia Personal Teléfono Carta

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KONSEY ADMINISTRASYON DISTRI LEKOL COLLIER COUNTY DEPATMAN POU SEVIS ELEV YO

5775 Osceola Trail, Naples, Florida 34109 Telefòn: 239-377-0505

DEKLARASYON SOU ENTANSYON POU TEMINE ENSKRIPSYON NAN LEKOL LA

Non Elèv la: Siyati, Non, Non Mitan Dat li Fèt I.D. # Adrès: Ri Vil Kòd Postal Nimewo Telefòn Lekòl Klas _________________________________________________________________________________________ Non/Tit Temwen Mwen gen sèz (16) an oubyen mwen pi gran e mwen gen entansyon tèmine enskripsyon mwen kòm yon elèv regilye nan Konsèy Administrasyon Distri lekòl Collier County-a. • Mwen konprann ke mwen kapab riske redwi kantite kòb mwen ka touche lè m-ap travay pandan

ekzistans mwen si mwen kite lekòl avan ke mwen gradye. • Mwen konprann ke mwen oblije ale nan Depatman Sikilasyon ak Motè Veyikil ki pral sispann lisans

mwen oubyen anpeche ke mwen gen yon lisans. • Mwen konprann ke yo pral voye non mwen bay yon Depatman ki rele “Department of Children &

Families” e ke, si fanmi mwen ap resevwa asistans finansyè, yo kapab redwi kantite kòb la. _________________________________ _________________________________ Siyati Elèv la (ekzijib) Siyati Paran/Responsab la* *si li pa disponib, avize nou ____________________________________ Dat Avi pou Paran yo sou Deklarasyon Elèv la sou Entansyon li pou Tèmine Enskripsyon li nan Lekòl la Moun ki Avize Paran an:_________________ Dat yo Avize li:______________ Metòd yo Itilize pou fè Avi a pase: Konferans Telefòn Lèt

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Appendix H OFFICE OF STUDENT SERVICES

5775 Osceola Trail Naples, FL 34109 (239) 377-0505 (239) 377-0506 FAX

Sent Via Outlook M E M O R A N D U M DATE: August 1, 2012 TO: All Principals FR: Christy M.P. Kutz, Director, Student Services

RE: Registration and Enrollment – Power of Attorney

As a result of the increasing use of Powers of Attorney and Statements of Acceptance of Responsibility forms for student registration and enrollment purposes, the following guidelines have been developed, with legal consultation from Mr. Jon Fishbane, in the interest of student safety and welfare as it relates to child custody: 1. Per the district Guidelines for Registration and Enrollment, only a parent or legal guardian may

enroll a child in school. 2. If anyone other than a parent attempts to enroll a child in school, Student Services must be

contacted by school staff prior to enrollment, to determine whether the adult is a legal guardian. 3. Student Services will review documentation on a case-by-case basis with legal, as needed to

establish child custody issues, with preference given to blood relatives. 4. Student Services will inform school staff of enrollment decisions. Please work with and through the Department of Student Services to assure that students are legally protected.

Approved by: ______________________________________ Date: __________

Beth E. Thompson, Chief Instructional Officer

cc: Mr. Jon Fishbane, District General Counsel Beth E. Thompson, Chief Instructional Officer Student Services Coordinators Attendance Assistants Data Entry, All Guidance Secretaries, Middle and High

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Appendix I

Florida Department of Education Exit Interview Student Survey

School Name School District

Student Name Student DOB

Grade Level Date

Directions: Please circle the response that best describes your experience or provide a description of your experience in the space provided.

1. Which of the following best describes your primary reason for terminating school enrollment?

A. Classes were not interesting/bored K. Student-teacher conflict B. Missed too many days and could not catch up L. Employment/have to work full-time C. Did not like school M. Friends dropped out D. Failing classes/couldn’t keep up with school work N. Failed to pass FCAT E. Illness O. Intimidated/Threatened/Bullied F. Became a parent P. Migrant G. Getting married Q. Homeless H. Felt like I did not belong R. Family Problems I. Suspended from school often S. Other J. Expelled from school

2. Which of the following best describes your secondary reason for terminating school enrollment?

A. Classes were not interesting/bored K. Student-teacher conflict B. Missed too many days and could not catch up L. Employment/have to work full-time C. Did not like school M. Friends dropped out D. Failing classes/couldn’t keep up with school work N. Failed to pass FCAT E. Illness O. Intimidated/Threatened/Bullied F. Became a parent P. Migrant G. Getting married Q. Homeless H. Felt like I did not belong R. Family Problems I. Suspended from school often S. Other J. Expelled from school

3. What would have improved your chances of staying in school? (Circle all that apply.)

A. Opportunities for real-world learning (internships, service learning) B. Better teachers C. Smaller classes D. More individualized instruction E. Better communication with your teachers F. Better communication with your parents G. Increased parental involvement

39

H. Less freedom and more supervision from parents I. Less freedom and more supervision from school officials J. Other

4. What actions did your school personnel take to keep you enrolled in school? (Circle all that apply.)

A. Provided student counseling I. Discussed and offered participation in a B. Scheduled a conference with parent(s), guardian(s), credit recovery course/program

student, and school staff J. Discussed and offered access to Dropout C. Discussed and offered options for tutoring Prevention Program(s) (e.g., alternative D. Discussed the consequences of dropping out education, disciplinary, teenage parent) E. Discussed and offered options for continuing K. Tracked student progress (by teacher,

education in a different environment (e.g., Adult counselor, social worker, graduation coach, Education, home school, virtual school, hospital etc.) homebound) L. Changed or revised course schedule

F. Discussed and offered alternative options for M. Implemented intervention contracts (e.g. graduation (e.g., diploma options or GED Testing) attendance or behavior)

G. Conducted home visits N. Student reported that school staff took no H. Referred student to agencies/programs to address action

problems interfering with school success (e.g., O. Other substance abuse counseling, psychological counsel- Z. Not Applicable. Student did not drop out ing, family counselor) of school or did not provide information

about actions taken Please check and sign below to certify that each of the following statements was addressed by school personnel.

I am at least 16 years of age and it is my intent to terminate my school enrollment. I received counseling from a guidance counselor or other school personnel which addressed the following: Terminating school enrollment prior to graduation will likely reduce my potential earnings and negatively

affect my career options. Termination of school enrollment will result in the revocation/denial of my driving privileges until age 18. My reasons for leaving school prior to graduation. Possible actions that could keep me from leaving school prior to graduation. Options for continuing my education in a different environment, e.g., Adult Education or GED testing. For Bright Futures eligibility, GED students must complete credit requirements before taking GED exam.

Student Signature: Date:

Parent/Guardian Signature: (if student is under 18 years of age)

Date:

School Personnel Signature: Date: Optional: 1. What is the highest level of education completed by your maternal parent/guardian?

(circle one) Elementary Middle School High School College Graduate School Unknown

2. What is the highest level of education completed by your paternal parent/guardian? (circle one) Elementary Middle School High School College Graduate School Unknown

40