Odyssey Charter School Enrollment Document Checklist · 1. Complete enrollment documentation along with medical/health, disciplinary, academic records, and special education or gifted

Odyssey Charter School Enrollment Document Checklist 14 St. John Circle ____-____ Academic Year

Newnan, Georgia 30265 www.odysseycharterschool.net

770-251-6111 Fax: 770-251-8200 [email protected]

Name ___________________________________________ Grade__________________

School Year ____________

The following documents listed below are requested to complete enrollment before your scholar starts school.

Forms marked with an asterisk may be obtained in the enrollment packet on the school website at www.odysseycharterschool.net.

Application for Admission*

Enrollment Information*

Immunization Certificate - GA Dept. of Human Resources Form 3231 or notarized affidavit

signedby all parents/legal guardians that swears or affirms that immunization(s) required conflict with

religious beliefs (however immunizations may be required in cases when such disease(s) is/are in epidemic

or breakout stages.)

Hearing-Vision-Dental-Nutrition Certificate - GA Form 3300 (revised 2013)

State-Issued, Certified Copy of Birth Certificate

Copy of Driver’s License of Enrolling Parent (for record of parent/guardian I.D.)

Copy of Student’s Social Security Card

Affidavit of Residence*

(must be accompanied by the 2 proofs of residence listed below/needs to be notarized –

our school has a notary)

Two Proofs of Residence

(One must be a voter registration card, mortgage bill, property tax bill or current lease.

The other may be a utility bill.)

Considerations and Exceptions for Enrollment/Parental Pledge Agreement*

Enrollment Assessment Questionnaire*

Proof of Custody/Guardianship/Foster/Adoption (if applicable)

Authorization to Give Medication at School (request if prescription medication is taken at school)

Release of Information Authorization*

Parent Occupational Survey

NAMES OF PARENTS AND SCHOLARS LISTED ON ENROLLMENT MUST

COINCIDE WITH ALL SUPPORTING DOCUMENTATION OR LEGAL

PROOF OF NAME CHANGE MUST BE PROVIDED.

http://www.odysseycharterschool.net/

Odyssey Charter School Application for Admission 14 St. John Circle ____-____ Academic Year



Student Enrollment Information t

Age (as of 09-01-20__): _________ Gender (circle one): M F Birth Date ________/________/________

Grade Enrolling In: Kindergarten 1st 2nd 3rd 4th 5th 6th 7th 8th

Previous Grade (20__-20__): Pre-K K 1st 2nd 3rd 4th 5th 6th 7th

Student Information

Student's Legal Name ___________________________________________________________________________ first middle last

Preferred Name ________________________________________________________________________

Student’s Residence Address: (Note: No P.O. Boxes)

Street:_________________________________________________________________________________________

City: ___________________________________________ State: ______________________ Zip: _______________

Student’s Current Mailing Address: ڤ Same as Residence Address

Street:_________________________________________________________________________________________

City: ___________________________________________ State: ______________________ Zip: _______________

Home Phone Number: (_________)________________________________________________________________

Preferred E-mail address: ________________________________________________________________________

Parent/Guardian Information

Student Lives With: ڤ Both Parents ڤ Both Parents Alternately (Joint legal custody) ڤ Mother Only

Other ڤ Legal Guardian ڤ Father Only ڤ

Legal Parent/Guardian #1 Legal Parent/Guardian #2

Name of parent/guardian

ACTUAL RELATIONSHIP

Address same as student same as student

Address (continued)

City, State, Zip

Home Phone

Employer

Work Phone

Cell Phone

E-mail address

Resident of Coweta County? Yes No Yes No

How did you hear about Odyssey? ___________________________________________________________________________

Parent Signature:___________________________________ Date received: ________________________

Odyssey Charter School Enrollment Information 14 St. John Circle ____-____ Academic Year


770-251-6111 [email protected]

For School Use Only:

GTID# ______________________________ SS# ______________________________ Enroll Date ________________

Student Enrollment Information Educational Place men Info r

Grade Enrolling for 20__-20__: K 1st 2nd 3rd 4th 5th 6th 7th 8th

Previous Grade (20__-20__): Pre-K K 1st 2nd 3rd 4th 5th 6th 7th

Student Information

Student's Name (as listed on birth certificate)_____________________________________________________________ first middle last

Preferred Name _______________________________ Gender (circle): M F Birth Date _____________________

Student’s Residence Address: (Note: No P.O. Boxes)

Street:____________________________________________________________________________________________

City: ______________________________________________ State: ______________________ Zip: _______________

Ethnicity (check one) Hispanic Non-Hispanic

Race (check all that apply): Caucasian Black or African American Asian

American Indian or Alaska Native Native Hawaiian or other Pacific Islander

Previous School Information

Previous Schools (most current first) Grades Years

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Type of School: Public School Private School Home School Charter School Preschool

Not in School Other (specify) _____________________________________________________

Name of Preschool__________________________________________ Public Private None

Address of Last School Attended:

Street: ___________________________________________________________________________________________

City: ___________________________________________ State: ______________________ Zip: __________________

School Phone Number: (_______) ___________________________________________________________________

Has your child ever been retained? No Yes

If yes, for what reason? __________________________________________________ Grade retained: ___________

Special Programs

Has your child been evaluated for and/or participated in any of the following special services?

Gifted & Talented Title 1/Chapter 1 Program Literacy Program (ILP) Speech Services

Babies Can’t Wait OT Services Early Intervention Plan (EIP) Special Education (IEP)

Response to Intervention (RTI) English as Second Language (ESL) 504 Plan

Other (specify): ______________________________________________________________________________

If you checked Special Education (IEP) or Gifted, do you have a copy of the records? Yes No

If you checked 504 Plan, indicate if plan is for academic or health reasons: _________________________________

Home Language Survey

Country of Student’s Birth:_________________________________________________________________

If not the U.S., what date did the student first enroll in a U.S. school? ______________________________

A. Which language does your child most frequently speak at home? _______________________________

B. Which language do adults in your home most frequently use when speaking to your child?__________

C. Which language(s) does your child currently understand or speak? _____________________________

D. If possible, would you prefer notice of school activities in a language other than English? Yes No

If yes, which language? ____________________________

Sibling Information

Siblings Enrolled at Odyssey Enrollment Status Home Phone Relationship to Student

New Currently Enrolled ( )




Other Children Living in Household Relationship to Student Birth Date

Student Residency Questionnaire Your child may be eligible for additional educational services through the Federal McKinney- Vento Homeless

Education Assistance Act. Eligibility can be determined by completing the "Student Residency" questionnaire below.

If none of the below apply, please write “not applicable” here:___________________________________________

Current Living Situation: (Check one)

In an emergency or transitional shelter

Awaiting foster care placement

Sharing the housing of others due to loss of housing, economic hardship, similar reason: double-up

Living in a car, park, campground, public space, abandoned building, substandard housing or similar

Temporarily living in a motel or hotel due to loss of housing, economic hardship or similar reason

Long-term, cooperative living arrangement to save money or a similar reason

A convenient living arrangement while waiting for an apartment or house to be ready

Current Address City Zip Code (Area Code) Phone Number

How long have you been residing at this location?

How long do you anticipate residing at this location?

Are you contributing financially to the household?

Unaccompanied Youth: Student is with an adult that is not a parent or legal guardian, or alone with an adult.

No, student(s) is with a parent, legal guardian, or biological parent.

Yes, caregiver must complete Caregiver's Authorization Form

Student Name (print)

First Last M/F Date of Birth Grade School Name

Declaration of Trust and Good Faith: I hereby declare that all of the above information is complete and accurate. I understand that failure to disclose important information or falsifying information on this application could result in the disenrollment of my child.

Parent/Guardian Signature:_______________________________________ Date:____________________

Student Name________________________________________ Birthdate__________________ Grade_____________

Emergency Contacts Academic Year 20__-20__

Mother_____________________________________________

Home Phone:_____________________ Cell Phone:_____________________ Work Phone:______________________

Father_____________________________________________

Home Phone:_____________________ Cell Phone:_____________________ Work Phone:______________________

Home Address: __________________________________________________ City _______________ Zip ___________

Email Address: __________________________________________________

Has any contact information changed since this form last completed? Yes No

If yes, what information has changed? (address/email/phone, etc)__________________________________________

If parents cannot be reached, list two nearby persons who will assume the care/responsibility of/for your child.

Name__________________________ Relationship______________ Phone_________________( cell home work)


List below any person who is allowed to pick up your child from school other than those listed above.



Health Insurance and Health Information (Answer ALL questions-write “none” if none) Primary Physician Information:

Doctor Name: __________________________________________ Doctor Phone: (____) ________________________ (First) (Last)

Other Doctors Providing Care for Student: Type of Doctor/Specialist Doctor Name Doctor Phone Reason

( )

( )

Insurance Provider:________________________________________ or Medicaid PeachCare No health insurance

Please list any serious allergies or conditions AND whether EpiPen is used (WRITE NONE IF NONE): __________________________________________________________________________________________________

Please list any and all medical, physical or emotional issues, problems or disabilities (WRITE NONE IF NONE): __________________________________________________________________________________________________

Does your child have asthma? ____________________ If yes, does he/she require an inhaler?______________

Please list any prescribed medications taken routinely AND whether they are taken at home or at school (WRITE

NONE IF NONE):______________________________________________________

*Please circle medications that may be given to your child by the school nurse: (*Please note: NO MEDS ARE PROVIDED BY THE CLINIC. They must be furnished in original container with the child’s

name clearly marked by the parent and kept in the clinic.)

Acetaminophen Ibuprofen Benadryl Cold/Cough/Allergy Chloraseptic Spray Tums/Antacid Cough Drops

*List other meds that may be given to your child________________________________________________________

Permission to Treat and Emergency Release

I give Odyssey School clinic staff permission to treat and to administer medications as indicated above. Odyssey School will attempt to reach the parent/legal guardian

or one of the people listed as an emergency contact. In the case of a serious illness/injury Odyssey School personnel have my permission to use discretion in securing

medical aid in an emergency, including dialing 911 for immediate transportation to the closest hospital or hospital of choice. IT IS UNDERSTOOD THAT NEITHER

ODYSSEY SCHOOL NOR THE PERSON RESPONSIBLE FOR OBTAINING THIS MEDICAL AID WILL BE RESPONSIBLE FOR ANY EXPENSE OR

LIABILITY INCURRED. I will notify Odyssey Charter School immediately in writing of any changes to my contact and/or health information.

Parent/Guardian Signature: ________________________________________________ Date: ___________________

Hospital Preference: 1st choice ______________________________ 2nd choice _______________________________

Odyssey Charter School Affidavit of Residence* 14 St. John Circle ____-____ Academic Year



The undersigned, first being duly sworn, deposes and says that he/she is the parent/guardian of the student or

student(s) listed below and said student or student(s) live with the undersigned, and that both the student or

student(s) and the undersigned are bona fide fulltime residents of Coweta County and that they reside at

(List Complete Residence Address) ______________________________________________________________

with (List Name of Residence Owner/Lessee) ______________________________________________________.

Student’s Legal Name Grade Name of school attending in 20__-20__

1.

2.

3.

4.

5.

Previous home address/phone number/name of school

Signature of Parent/Guardian Home Phone Number (must agree with name of residence owner/lessee above)

Cell Phone Number

*Any person who knowingly and willfully makes a false, fictitious, or fraudulent statement or representation,

or makes or uses any false writing or document, knowing the same to contain any false, fictitious, or

fraudulent statement, in any matter within the jurisdiction of any department or agency of the government of

any political subdivision of this State, including a school system, shall, upon conviction thereof, be punished

by a fine of not more than $1,000.00 or by imprisonment for not less than one nor more than five years, or

both. Ga. Code §16-10-20.

I have read and understand the foregoing statement.

Parent/Guardian Initials

Sworn to and subscribed before me this _______

day of _______________________, 20_________.

(Notary Seal) (Notary Public) Revised / March 2016

Odyssey Charter School Considerations and Exceptions for Enrollment 14 St. John Circle ____-____ Academic Year



1. Complete enrollment documentation along with medical/health, disciplinary, academic records, and special education

or gifted records (if applicable) from previous school(s) must be received by Odyssey School before an enrollment is

considered complete. Students are subject to the board policies regarding admission and enrollment at the time their

admission is considered complete.

2. Studies of individual families show that family participation is more important to student success than any other

factor. These studies indicate that if parents spend one hour reading or working on school work five days a week, the

dollar benefit to the American taxpayer would equal almost what this nation pays annually for the entire K-12 public

education system. By signing the pledge below, you agree to take personal responsibility for your child’s education.

3. Check any/all of the below that apply to you child. Odyssey School does not accept students who meet any of the

following criteria at the time of enrollment:

Student is currently suspended from another school or school system

Student has been expelled from another school or school system

Student has been formally asked to leave a school

Student is awaiting a discipline tribunal

Student is awaiting a court date

Student is currently attending or has been placed into an alternative educational setting

Currently serving time in a correctional facility

Student has a discipline situation against him/her which restricts them from attending their zoned public school

within the local school district

Students meeting any of the criteria above are not eligible to attend Odyssey until they are eligible to attend their

zoned public school within the local school district or, in the case of a private school, eligible to return to that private

school.

Parental Pledge

I have read carefully and understand the above considerations and exceptions for enrollment at Odyssey School.

Disagreement with any of these considerations and exceptions should be a determining factor in your choice to enroll at

Odyssey School.

As the parent(s)/guardian(s) of ___________________________________________, we/I understand that we/I accept the

responsibility to participate in our/my child’s education. Therefore, we/I pledge to help my child with homework and/or

reading a minimum of 15 minutes per night. We/I also pledge to volunteer a minimum of 18 hours service per year at

Odyssey Charter School.

Declaration of Trust and Good Faith: I hereby declare that all of the above information is complete and accurate. I understand that failure to disclose important information or falsifying information on this application could result in the disenrollment of my child.

Parent/Guardian Signature:____________________________________________ Date:______________________

Odyssey Charter School Enrollment Assessment Questionnaire 14 St. John Circle ____-____ Academic Year



Student Information

Student's Name (as listed on birth certificate) _____________________________________________________________ first middle last

Preferred Name _____________________ Birth Date ________________ Grade________________

Historical Information

Why have you decided to enroll your child in Odyssey Charter School? _____________________________________

__________________________________________________________________________________________________

Does your child have any learning challenges? __________________________________________________________

__________________________________________________________________________________________________

Does your child have any problems at school; if so, what are they? _________________________________________

__________________________________________________________________________________________________

Is your child absent often? If yes, why? ________________________________________________________________

Has your child ever been tutored? _______ If yes, for how long and for what? _______________________________

__________________________________________________________________________________________________

What does your child enjoy about school? ______________________________________________________________

What talents does your child have? ___________________________________________________________________

Tell us about your child’s strengths and needs, both academic and social.____________________________________

__________________________________________________________________________________________________ Were there any difficulties with your child’s birth? If yes, explain. _________________________________________

__________________________________________________________________________________________________ Were there any developmental issues during your child’s early years? If yes, explain. _________________________

__________________________________________________________________________________________________ Does your child have any problems with vision or wear glasses/contacts? ____________________________________

Social History and Information Please check the following positive attributes your child may exhibit:

Cheerful Motivated Good eye hand coordination Cooperative Considerate Enjoys drama/performing Creative Athletic Musically inclined

Friendly Artistic Good reading skills Good leader Mechanically inclined Good math skills Kind/helpful Shows initiative Enjoys science Works/plays well with others Hard worker Other/explain:

What family concerns may be influencing your child at this time? (Check all that apply.) ______None ______Emotional abuse ______Parent illness ______Parent in military ______Alcohol abuse ______Job related ______Physical abuse ______Death ______Moves often ______Separation/divorce ______Drug abuse ______Parent absent from home ______Sickness/physical difficulties

Comments: _______________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________

Check if there is a family history of any of the following and indicate relationship of the person to the child: Relationship Relationship

Hyperactivity Behavioral problems Attention difficulties Neurological problems

Drug abuse Special education services Alcoholism Speech/ language problems Eating disorders Mental retardation Suicide Slow learner Depression Autism spectrum/Asperger’s Anxiety Reading problems

Bipolar disorder Math problems Schizophrenia Writing problems Phobias Other

Check any of the following that may impact your child’s academic performance:

Short attention span Moody Sad Fidgety Controlling Depressed

Disorganized Oppositional Difficulty with social skills Impulsive Stubborn Has few friends Lacks self control Aggressive Follower Overly energetic in play Difficulty controlling anger Withdrawn Overreacts Irritable Poor self esteem Difficulty following directions Easily frustrated/lacks patience Does not respond to/exhibit affection

Nervous/anxious Compulsive Shows little emotional response Immature Night terrors Lethargic Does not adjust to change Lies often Cries easily Destroys property Steals Lacks motivation Plays with or sets fire Cruel to animals Inappropriate fears Self-injurious Inappropriate sexual behavior Other-explain

Check if your child has ever been seen by the following: Reason Beginning Date Ending Date

Counselor Social worker Psychologist Psychiatrist Probation officer

Declaration of Trust and Good Faith: I hereby declare that all of the above information is complete and accurate. I understand that failure to disclose important information or falsifying information on this application could result in the disenrollment of my child. Parent/Guardian Signature:____________________________________________ Date:______________________

Odyssey Charter School Authorization to Give Medication at School 14 St. John Circle ____-____ Academic Year



Odyssey Charter School Release of Information 14 St. John Circle ____-____ Academic Year



REQUEST FOR RECORDS/TRANSCRIPT

We are requesting the records/transcript for __________________________________________

Date of Birth _____________ from their previous school, _______________________________

The student has registered at Odyssey Charter School in the ______ grade.

Please fax or mail the following information:

Birth Certificate

Social Security Card

Certificate of Immunization (GA 3231)

Certificate of Hearing/Vision/Dental Form (GA 3300)

Copy of final report card or current grades

Standardized tests for achievement

Gifted –Eligibility Records

ESOL Eligibility Records / W-APT/ACCESS Scores

504 Plan

Attendance Records

Discipline Records

_______________________________________________ ________________________

Registrar Signature Date

I give permission for Odyssey Charter School Staff to speak to and request information/records

from ____________________________________________ at ___________________________

Regarding my Son/Daughter (Circle One)

______________________________________________________________________________

This release is valid for one year from the date of signature.

Printed Name: _____________________________________ Date: ___________________

Signature: _____________________________________________________________________

Richard Woods, Georgia’s School Superintendent “Educating Georgia’s Future”

1858 Twin Towers East • 205 Jesse Hill Jr. Drive • Atlanta, Georgia 30334 • www.gadoe.org An Equal Opportunity Employer

School District:_____________________ Date:_________________

Parent Occupational Survey Please complete this form to determine if your child(ren) qualify to receive supplemental services under

Title I, Part C Name of Student(s) Name of School Grade ____________________________________ _____________________________ __________________ ____________________________________ _____________________________ __________________ ____________________________________ _____________________________ __________________ ____________________________________ _____________________________ __________________

1. Has anyone in your household moved in order to work in another city, county, or state, in the last three (3) years? Yes No 2. Has anyone in your household been involved in one of the following occupations, either full or part-time or temporarily during the

last three (3) years? Yes No If you answer “yes”, check all that applies:

1) Planting/picking vegetables (such as tomatoes, squash, onions) or fruits (such as grapes, strawberries, blueberries) 2) Planting, growing, cutting, processing trees (pulpwood), or raking pine straw 3) Processing/packing agricultural products 4) Dairy/Poultry/Livestock 5) Meatpacking/Meat processing/Seafood

6) Fishing or fish farms 7) Other (Please specify occupation): ____________________________________________________________________

Names of Parent(s) or Legal Guardian(s) ______________________________________________________________ Current Address: ____________________________________________________________________________________ City: ________________________State: _____________ Zip Code: _____________Phone: __________________________

Thank You! Please return this form to the school

Please maintain original copy in your files.

MEP funded school/district: Please give this form to the migrant liaison or migrant contact for your school/district. Non-MEP funded (consortium) school/districts: When at least one “yes” and one or more of the boxes from 1 to 7 is/are checked, districts should fax occupational

surveys to the Regional Migrant Education Program Office serving your district. For additional questions regarding this form, please call the MEP office serving your district:

GaDOE Region 1 MEP, P.0. Box 780, 201 West Lee Street, Brooklet, GA 30415

Toll Free (800) 621-5217 Fax (912) 842-5440

GaDOE Region 2 MEP, 221 N. Robinson Street, Lenox, GA 31637 Toll Free (866) 505-3182 Fax (229) 546-3251

Regional Office use only:

Richard Woods, Georgia’s School Superintendent “Educating Georgia’s Future”

1858 Twin Towers East • 205 Jesse Hill Jr. Drive • Atlanta, Georgia 30334 • www.gadoe.org An Equal Opportunity Employer

Distrito Escolar: ______________________ Fecha: _________________

Encuesta Ocupacional para Padres Favor de completar este formulario para ayudarnos a determinar si su(s) hijo(s) califica(n) para

recibir servicios suplementarios de parte del Programa de Título I, Parte C

Nombre del/los Estudiante(s) Nombre de la Escuela Grado ____________________________________ _____________________________ __________________ ____________________________________ _____________________________ __________________ ____________________________________ _____________________________ __________________ ____________________________________ _____________________________ __________________

1. ¿Alguien en su casa se ha mudado para trabajar en otra ciudad, condado, o estado, en los últimos tres (3) años? Sí No 2. ¿Alguien en su casa trabaja, ha trabajado, o tiene la intención de trabajar en una de las siguientes actividades de forma permanente

o temporaria, o ha hecho este tipo de trabajo en los últimos tres años? Sí No Si la respuesta es “si”, marque todo trabajo que aplique:

1. Sembrando/cosechando vegetales (como tomates, calabazas, cebollas, etc.) o frutas (como uvas, fresas, arándanos, etc.) 2. Sembrando, cortando, procesando árboles, o juntando paja de pino (pine straw) 3. Procesando/empacando productos agrícolas 4. Trabajo en lechería o ganadería 5. Trabajo en empacadoras o procesadoras de carnes (como de res, pollo o mariscos) 6. Pezca o crianza de peces 7. Otra actividad. Por favor especifique en cuál: _________________________________________________________

Nombre de los padres o guardianes legales: ______________________________________________________________ Dirección donde vive: ________________________________________________________________________________ Ciudad: _______________ Estado: __________ Código Postal: _______________ Teléfono: ______________________

¡Muchas Gracias!

Por favor regrese este formulario a la escuela

Please maintain original copy in your files. MEP funded school/district: Please give this form to the migrant liaison or migrant contact for your school/district.

Non-MEP funded (consortium) school/districts: When at least one “yes” and one or more of the boxes from 1 to 7 is/are checked, districts should fax occupational surveys to the Regional Migrant Education Program Office serving your district. For additional questions regarding this form, please call the MEP office serving your

district:

GaDOE Region 1 MEP, P.0. Box 780, 201 West Lee Street, Brooklet, GA 30415 Toll Free (800) 621-5217 Fax (912) 842-5440

GaDOE Region 2 MEP, 221 N. Robinson Street, Lenox, GA 31637

Toll Free (866) 505-3182 Fax (229) 546-3251

Regional Office use only:

Documents

Odyssey Charter School Enrollment Document Checklist · 1. Complete enrollment documentation along with medical/health, disciplinary, academic records, and special education or gifted