PLEASE MAIL YOUR REGISTRATION PACKET TO THE FOLLOWING:

CHARLOTTE VIRTUAL SCHOOL

ATTN: MELANIE EASTMAN

18150 MURDOCK CIRCLE

PORT CHARLOTTE, FL 33948

Form 9035-1004 Rev. 02.20 Student Success! Side 1 of 2

SCHOOL _________________

STUDENT REGISTRATION FORM PRE-K THROUGH ADULT

(Appendix 4)

Please check here if your child has been enrolled in Charlotte County Public Schools before.

Student’s name as it appears on birth certificate.

Last Name First Name

Middle Name Appendage

Grade Military Family Yes No

Are you of Hispanic or Latino descent Yes No What is your race (Please check all that apply)

American Indian / Alaskan Native Asian Black / African American Native Hawaiian / Pacific Islander White

Sex Have you come to the U.S. in the past 3 years from today’s date Yes Date No

Birthplace Country of Birth

Birthdate Custody Alert with documentation Yes No

Residence Address (This is the address used for school assignments and CANNOT be a Post Office Box)

Current residence is temporary/transitional (If checked, complete the Affidavit of Residency Form, Appendix 17)

Residence Address Apt./Bldg. #

City State Zip Code

County (if not Charlotte) D=Desoto, L=Lee, S=Sarasota No

Mailing Address (if different from residence address)

Street Apt./Bldg. #

City State Zip Code

Primary Contact Number

Parent/Guardian/Caregiver

Parent/Guardian/Caregiver

Parent/Guardian/Caregiver

Emergency Name

E-mail

Previously enrolled in a Florida School Yes No

If yes, County If no, State/Territory Country

Previously attended Pre-K Yes No If yes, where?

Form 9035-1004 Rev. 02.20 Student Success! Side 2 of 2

STUDENT REGISTRATION FORM PRE-K THROUGH ADULT

(Appendix 4)

(MUST ANSWER)

Have either of the parents/guardians moved within the last three years from another county/state due to

working in agriculture, fishing or dairy activities? Yes No

Where did you attend 3 - 10 Grade School County/State

Did you take the FSA at the above school Yes No

If No, where, school

County

Year you first entered 9th Grade, if applicable

Did you take an End of Course Exam (EOC) Yes No If Yes, where

Did you take online courses(s) Yes No If Yes, where

Were you receiving services Special Education 504 ELL Other

Does the student receive Social Security Benefits Yes No

Home Language Survey (Administered by school registrar)

School: __________________________________ Student FLEID#_____________________________

Student’s Last Name: ______________________

Student’s First Name: _____________________

1. Is a language other than English spoken in your home? No Yes __________________________ (specify language)

2. What is the language most often spoken by the student? ___________________ (specify language)

3. Which language did your child learn first? ___________________________ (specify language)

4. In which language do you prefer to receive information from the school? ____________________________ (specify language)

5. What is your relationship to the child? Father Mother Guardian Other (specify)

6. What date did the child enter school in the United States? ________________________________________

I understand that answering yes to one or more of these questions will result in my child being screened for ELL Services

Signature Parent/Guardian/Caregiver_____________________________________ Date _________________

SCHOOL USE ONLY

If one or more responses to the home language survey above are YES, contact the ELL (ESOL) Department immediately for the proper code.

LEP Status Code Student Language Code

Parent Code P = Parent G = Guardian O = Other Relative A = Guardian Ad Litem S = Surrogate Parent N = Not Required

Birthdate Verification 1 = Certified Copy of Birth Certificate 5 = Passport 2 = Baptismal Certificate 6 = School Record 3 = Insurance Policy 7 = Physician’s Statement 4 = Bible Record 8 = Out of State

Continued

School:

SCHOOL REGISTRATION DISCLOSURE FORM (Appendix 5)

Florida Statute 1006.07 (1)(b) requires the disclosure of previous school expulsions, arrests resulting in a charge, juvenile justice Actions, and referrals to mental health services. Failure to provide accurate information can result in denial of educational participation.

Student Name: Last, First, Middle Date of Birth Social Security # (optional)

Street Address City State Zip Code

/ Home Telephone / Cell Phone Parent/Guardian/Caregiver Name

Has the above named student ever been expelled or placed on a stipulated agreement in lieu of expulsion from a school or

school system? Yes No If yes, complete the following section:

Approximate Approximate Date Began Date Ended Location of School Reason for Expulsion/Stipulated Agreement

Has the above named student ever been arrested and/or charged with a juvenile or adult crime? Yes No If yes, complete the following section: (three most recent events) Approximate Date Arrest Charge Juvenile Adult Reason

Has the above named student ever been involved with Juvenile Justice? Yes No If yes, complete the following section: Approximate Approximate Date Began Date Ended STATUS

Has the above named student ever been referred for mental health services by another school system? Yes No If yes, complete the following section: Approximate Type of Mental Health Service Received Date(s) of Service

The above information is correct and true.

Student Signature Parent/Guardian/Caregiver Signature

If YES please distribute: Student File Parent/Guardian/Caregiver Director of Student Services Form: 9035-1005 Rev: 06.19 Appendix 5

Student Success!

3-5

Grade: School: Teacher: School Year: Siblings attending this school:

STUDENT HEALTH ASSESSMENT

(APPENDIX 9)

Student’s Name: DOB: Home Phone:

Address: Zip Code:

Mailing Address (if different) Zip Code:

1. Parent/Guardian/Caregiver: Cell No. Work No.

2. Parent/Guardian/Caregiver: Cell No. Work No.

Child lives with: Both Parents Mother Father Other

Emergency Caregivers If Parent/Guardian Unavailable Name: Relation: Cell No. Work No. Home No. Name: Relation: Cell No. Work No. Home No. Name: Relation: Cell No. Work No. Home No.

Medical History: Please check if your child has been diagnosed by a physician for any of the following:

ADD/ADHD Cystic Fibrosis Physical Handicap Asthma Diabetes Psychiatric Condition Bleeding Disorder Epilepsy/Seizures Speech Difficulty Bowel/Bladder Problem Hearing Problems Sickle Cell Disease Cancer Kidney Disorder Vision Problems (Glasses Yes No)

Cardiac Condition Other:

Please explain any items checked above:

Allergies: Please check if your child has been diagnosed by a physician for any of the following: Plants Foods Bees Drugs Animals Other Insects Other (Please specify) Please list reactions such as hives, difficulty breathing,

Is medication needed for allergy? Yes No If yes, name of medication:

Medication Treatment Will your child be taking medication during school hours? Yes No Name of Medication:

If yes, please provide a completed Charlotte County Public School Physician and Parent Medication Authorization Form. Does your child take medication at home? Yes No Name of Medication:

Do you have the following? Dental insurance coverage Yes No Vision insurance coverage Yes No

{For Pre-K Students Only: Is child potty trained?} Yes No

Authorization for Emergency Care/Transportation

In case of accident or serious illness, I request the school contact me. If the school is unable to reach me, I hereby authorize this school to transport my child by ambulance to Hospital. I understand that I am responsible for all expenses incurred. Signature: Parent or Guardian Date Form 9035-1009 Rev. 04/10 Appendix 9 Student Success!

PARENT/GUARDIAN/CAREGIVER CONSENT FORM (Appendix 11)

STUDENT NAME: GRADE:

(Please Print) Last First Middle

Directions: Initial the beginning of the following statements. All initialed areas must be completed.

______ BUS AGREEMENT FOR PRE-K, KINDERGARTEN, AND FIRST GRADE STUDENTS I understand the policy which requires that any Pre-K, kindergarten or first grade child be accompanied to the bus stop five minutes before pick-up time and met at the bus stop at the assigned return home time. I understand the bus driver will not allow my child to get off the bus unless I am physically present at the designated stop and able to take immediate custody of my child as they depart.

I understand that I must notify the school in writing of the person who will escort my child to and from the bus stop. The designated person

must be an adult daycare provider, a sibling in fifth grade or above, or an adult family member.

______ PERMISSION TO PHOTOGRAPH/VIDEO TAPE YES NO (Check one)

I give my permission to allow my child to be photographed or video taped for use in news stories and/or promotional materials that relate to the Charlotte County Public Schools. My consent applies only to the use of such materials for non-profit, non-commercial purposes.

______ DISPLAY OF STUDENT WORK YES NO (Check one)

I expressly license the school district to display my child’s work on any school district-owned website without any cost to the Board.

INTERNET PERMISSION YES NO (Check one)

I give my permission to allow my child to be photographed or video taped for use in news stories and/or promotional materials that relate to the Charlotte County Public Schools and are displayed on the Internet. My consent applies only to the use of such materials for non-profit, non-commercial purposes.

______ SCREENING, FURTHER ASSESSMENT PERMISSION YES NO (Check one)

I give permission for screening and further assessment of my child as necessary. (Below you will find a list of tests that may be given to your child

on an individual basis if they are needed. (This does not apply for group testing such as PSAT/NMSQT, FSA, NGSSS, and other state

mandated tests.) INTELLIGENCE TESTS: Kaufman Brief Intelligence Test (K-BIT)

DIAGNOSTIC TESTS: Progress Monitoring Assessments: iReady, USA Test Prep. Speech and Language Screening, FLKRS, DRA

OBSERVATIONS: School based personnel, student support personnel, ESE/Psychological Services personnel

______ HEALTH SCREENING PERMISSION (eyes,ears,height,weight,scoliosis GR6 only) YES NO (Check one)

______ RELEASE OF MEDICAL INFORMATION: YES NO (Check one) I hereby authorize for my child’s health information and parental contact information (collected from school provided health services) to be shared with emergency personnel, health department officials, and EMR systems.

HEALTHCARE NEEDS INCLUDING EMERGENCY CARE/TRANSPORTATION: ______ I understand that the school will provide onsite management and aid for illness or injury pending the students return to the classroom or

release to parent/guardian/caregiver. The school will call for emergency medical care as deemed necessary. Emergency transportation to a health care facility, as determined by paramedics, is authorized. Medical and other information will be disclosed without consent from the parent/eligible student in case of health emergencies, as permissible by FERPA. I understand that I am responsible for all expenses incurred.

RELEASE OF DIRECTORY INFORMATION

______ Under Federal Law, directory information (which may include name, address, phone number, date of birth, honors and awards) about

students can be released. This information MUST be released to the military unless parents opt out. ____ I am opting out and do not want any information about my child released to anyone (newspapers, etc.) except to those who have

a legal right. ____ I am opting out and do not want any information about my child released to the military.

Parent/Guardian/Caregiver Signature: ________________________________________

(MUST ANSWER)

Have either of the parents/guardians moved within the last three years from another county/state due to working in agriculture, fishing

or dairy activities? YES NO (Check one)

SURVEY PARTICIPATION I give permission for my child to participate in surveys such as the Florida Youth Substance Abuse Survey and other surveys relevant to the health, safety, and welfare of students. I understand that surveys of this type contain no personally identifiable information. I also understand that I may contact the school if I wish to review any survey.

YES NO (Check one) Parent/Guardian/Caregiver Signature:

Parent Name (print): Parent Signature: Date:

Form 9035-1011 Rev 02/20 Distribution: School Teacher Other Appendix 11

Student Success!

Approved Reassignment: ___ EMERGENCY CARD

(Appendix 10)

Student's Last Name, First Name: School Year:

Date of Birth: Gender ___________ Grade: Teacher:

Ph# to receive Automated Calls & Text Messages:

Ph# Parent/Guardian/Caregiver: _________________________ Ph#: Parent/Guardian/Caregiver:

Primary Email: Secondary Email:

Student’s Primary Address: Zip

Address Belongs to: ___ Mother ___ Father ___ BOTH ___ Guardian ___ Caregiver Other: _______________________________

Mailing Address (if different): Zip

Parent/Guardian/Caregiver Name: Relationship: Work Phone:

Parent/Guardian/Caregiver Name: Relationship: Work Phone:

Custody Alert NO YES* *Note: DOCUMENTATION REQUIRED: If there is a custody issue, please provide court documents. Please know that without court documents; your child can be released to another custodial parent.

NAME of CUSTODIAL PARENT/GUARDIAN:

Emergency Contacts, if Parent/Guardian/Caregiver Unavailable

Name Relation Phone Cell

Name Relation Phone Cell

Name Relation Phone Cell

Siblings: Name: School: Name: School:

Name: School: Name: School:

AFTER SCHOOL ARRANGEMENTS *Notify school immediately if these arrangements change in writing or in person. WALKER RIDE BUS # _________ _______________ CAMP/Daycare PARENT PICK-UP OTHER (please state)

MEDICAL CARE NAME OF PHYSICIAN PHONE

NAME OF DENTIST PHONE

Physician Diagnosed Medical Conditions

Physician Diagnosed Allergies

*It is the responsibility of the parent/guardian to notify the school nurse of any physician diagnosed medical conditions/allergies. The school will provide onsite management and aid for illness or injury pending the students return to the classroom or release to parent/guardian/caregiver. The school will call for emergency medical care as deemed necessary. Emergency transportation to a health care

facility as determined by paramedics is authorized. Medical and other information will be disclosed without consent from the parent/eligible student in case of health emergencies, as permissible by FERPA. I understand that I am responsible for all expenses incurred.

Signature of Parent/ Guardian/ Caregiver Date Preferred Hospital Form 9035-1010 Rev: 02/20 Appendix 10 Student Success!

20 

Student Internet Usage Agreement:

The Charlotte County Public Schools Acceptable Use of Technology Resources/Internet Usage Agreement

The Terms and Conditions for Internet use and this Agreement were written referencing School Board policies 7540, 7540.1, 7540.2 and 7540.3; Student Network and Internet Acceptable Use and Safety

STUDENT RESPONSIBILITY AGREEMENT

I, , student at Charlotte Virtual School, am making a request for school network/Internet access privileges. I have read this agreement, and I understand and agree to abide by the duties and responsibilities that go with my access to the network. I further understand that access to this network is a privilege and not a right, and that this privilege may be revoked at any time if I make inappropriate use of the network or fail to comply with the terms of the Charlotte County Public Schools Internet Usage Agreement. I may also be subject to school discipline for failure to comply.

Student’ signature Date

Form: 9035-1017 Revised: 3/17 Appendix 17 Student Success!

AFFIDAVIT OF RESIDENCY FORM

(Appendix 17)

This questionnaire is intended to address the McKinney-Vento Act 42 U.S.C. 11435. The answers to this residency information help determine the services the student may be eligible to receive.

Are you an Unaccompanied Youth? ChYes - The student is with an adult that is not a parent or legal guardian or is

alone without an adult.

No - The student does not meet the definition of “Unaccompanied Youth” Are you living in any of the following situations?

Yes No Code Definition

A Living in emergency or transitional shelters, FEMA Trailers, abandoned in hospitals.

B Sharing the housing of other persons due to loss of housing, economic hardship or a similar Double-up

D Living in cars, parks, temporary trailer parks, or campgrounds due to the lack of alternative adequate accommodations, public spaces, abandoned buildings, substandard housing, bus or train stations, public or private place not designated for or ordinarily used as a regular sleeping accommodation for human beings or similar settings.

Ch E Living in hotels or motels.

If you answered YES to any of the above, then your preschool-aged and school-aged children have certain rights, protections, and services under the No Child Left Behind Act: Title X, Part C. Please complete the information below.

Student Name: DOB: School: Grade:

Student Name: DOB: School: Grade:

Student Name: DOB: School: Grade:

Student Name: DOB: School: Grade:

Name of Parent/Legal Guardian/Caregiver

Since I/we have not had a permanent home; however, I/we have been residing within the Charlotte County Public School District boundaries and intend to remain there. I receive my mail and can be contacted at:

Email:

Address:

Phone Number: Cell:

I can be reached for emergencies at:

Revised: 3/17

I will notify the McKinney-Vento Liaison at (941) 255-7480 within five (5) working days of any change in my residence or the residence of the above mentioned child.

Parent/Guardian/Caregiver/Unaccompanied Youth: Date: CCPS Staff Member Signature: _________________________________________ School Initials: ___________

I cer t i f y the a bo v e name d s tude nt qua l i f i e s f o r the Chi ld Nutr i t io n Pro g ra m under the

pro v i s io ns o f the M cKinney -Vento Act .

Date McKinney-Vento Liaison Signature

PLEASE FAX TO THE FAMILIES FIRST OFFICE UPON COMPLETION @ (941) 255-7483