AES Step 2

Online Enrollment

Step 2 Document

2012-2013

Technology Use Form

Andover eCademy will provide a technology kit to each student enrolled in the virtual school for the 2012-2013 school year. The parent or legal guardian of the enrolled student must accept the technol-ogy use responsibilities listed below. To indicate that you understand the technology use responsibili-ties, please initial each line and provide your signature at the bottom of the page. Term: Students may use an Andover eCademy technology kit during the school year while enrolled in the school. Upon termination of a student’s enrollment, Parent/Guardian and student’s rights expire to possess the technology kit. Andover eCademy also reserves the right to terminate possession if the Parent/Guardian and/or student is believed to have violated any part of the agreement. The Parent/Guardian shall return the technology kit as instructed within two weeks of notification, in the same con-dition as delivered. Failure to return the technology kit will result in the Parent/Guardian being liable to Andover eCademy for the full value of the technology kit or for any required repairs, and for attorney fees and related costs in recovering the technology kit. Ownership: The technology kit is sole property of Andover eCademy. At no time will ownership be transferred to the Parent/Guardian or student. The technology kit must reside at the address provided on the student’s enrollment form. Written notice must be provided to Andover eCademy within 30 days if the address changes. Condition: The Parent/Guardian agrees to report a loss or damage that may occur to the technology kit within 24 hours of the occurrence. The Parent/Guardian is solely liable for any loss or damage that occurs to the technology kit. A loss or damage report must be submitted to Andover eCademy within 3 days of the occurrence. Maintenance and Repair: The Parent/Guardian is responsible for requesting maintenance and repair of the technology kit while in his or her possession. Use of Technology Kit: The parent/guardian agrees to the following:

The technology kit is to be used for the education of the student while enrolled at Andover eCademy and not for the benefit of any other person or for any other purpose. Each software application provided shall be subject to, and used in accordance with, the license

and/or use agreement that accompanies that software application. All usage of the technology kit shall be subject to Andover eCademy policies and rules regarding

Network/Internet use. (refer to handbook) The Parent/Guardian is solely responsible for ensuring that the software settings, default con-

figurations, and administrative privileges are maintained at the original specified settings that the technology kit had upon delivery and will be liable for any resulting damage to the technology kit.

The Parent/Guardian is solely responsible for keeping User IDs and passwords confidential to prevent unauthorized usage.

Insurance: The Parent/Guardian agrees to maintain at his or her expense adequate insurance to

cover damage to the technology kit by fire, theft, flood, explosion, accident or other cause to the full replacement value of the technology kit and agrees that he or she will be financially liable for it regard-less of the availability of insurance proceeds.

Name of Parent/Legal Guardian (please print)

Signature of Parent/Legal Guardian ____________ Date _____________

2012-2013 Fee Sheet

STUDENT’S NAME GRADE

All students are required to pay a Technology Fee. An “At-Risk Application” will be available in mid-

July for families who qualify for the free/reduced lunch program but do not have a lunch made available to

them. Students who qualify for free status will not have to pay the technology fee. Students who qualify for

reduced status will have to pay $12.50. The free/reduced status does not apply to the laptop deposit.

LAPTOP DEPOSIT: Please check the box that applies to you and enter the fee (if any) on the line below.

I will be using a new Andover eCademy Dell Laptop and my laptop deposit is $50.00 * *deposit is refundable when laptop is returned upon withdrawal from the program

I will be using a personal computer and my laptop deposit is $0.

LAPTOP DEPOSIT $_______________

TECHNOLOGY FEE $ 25.00

TOTAL FEES $_______________

Enrollment forms and fees may be mailed to our office or returned in person to 1413 N. Main St.,

Monday-Friday, 8:00 a.m.-4:00 p.m. Parents may pay fees using our online option or by check made payable

to “Andover USD 385.” To pay online, go to www.andoverecademy.org, click on the enrollment page and

follow the steps. Please make sure to put the student’s name and grade level in the description box.

The following pages

apply only to

students new to

Andover eCademy.

KANSAS CERTIFICATE OF IMMUNIZATIONS (KCI)This record is part of the student's permanent record and shall be transferred from one school to another as defined in Section 72-5209 (d) of the Kansas School Immunization Law (amended 1994.)

Student Name:

Parent or Guardian Name:

Address:

Birthdate (MM/DD/YYYY): SEX: [ ] MALE [ ] FEMALE

Phone:

Race: Ethnicity: County:

RECORD THE MONTH, DAY, AND YEAR THAT EACH DOSE OF VACCINE WAS RECEIVED

VACCINE7th6th5th4th3rd2nd1st

If additional doses are added,

please initial the dose and sign

below:

Polio Required for school entry.

HEP B (Hepatitis B) Required for school entry.

Varicella (Chickenpox) Required for school entry. 2 doses grades K-3 & 7-8.

One dose grades 4-6 and 9-12 for 2012-2013 school year.

MMR (Measles, Mumps, and Rubella combined) Required for school entry.

HIB (Haemophilus Influenzae Type B) Required < 5 years of age for preschool

or child care operated by a school.

PCV (Pneumococcal Conjugate) Required < 5 years of age for preschool or

child care operated by a school.

HEP A (Hepatitis A) Required < 5 years of age for preschool or child care

operated by a school.

Physician Signature:

MCV4 (Meningococcal) Initial dose recommended at 11-12 years of age and booster

dose recommended after 16 years of age. Not required for school entry.

DTaP/DT/Td/Tdap (Diphtheria, Tetanus, Pertussis) Required for

school entry. Single Tdap required for grades 7-10.

HPV (Human Papillomavirus) Recommended for males and females at

11-12 years of age. Not required for school entry.

Rotavirus Recommended < 8 mo. Not required for school entry.

Hx of Disease: Date of Illness:

DT DTaP Td Tdap DT DTaP Td Tdap DT DTaP Td Tdap DT DTaP Td Tdap DT DTaP Td Tdap DT DTaP Td Tdap DT DTaP Td Tdap

State Type

Influenza (Flu) Recommended annually for ages 6mo and older. Not

required for school entry.

MMR Me/Mu/Ru MMR Me/Mu/Ru

I certify I reviewed this student's vaccination record and transcribed it accurate

Agency Name:

1. "Annual written statement signed by a licensed physician (Medical Doctor/M.D. or Doctor of Osteopathy/D.O.) stating the physical

condition of the child to be such that the tests or inoculations would seriously endanger the life or health of the child." Medical

exemption shall be validated annually by physician completion of KCI Form B and attachment to the KCI.

2. "Written statement signed by one parent or guardian that the child is an adherent of a religious denomination whose

religious teachings are opposed to such tests or inoculations."

DateParent/Legal Guardian's Signature

I give my consent for information contained on this form to be released to the Kansas Immunization

Program for the purpose of assessment and reporting.

KANSAS IMMUNIZATION PROGRAM

1000 SW Jackson, Suite 075, Topeka, KS 66612-1274

PHONE 785-296-5591 FAX 785-296-6510

WEB SITE www.kdheks.gov/immunizeRev. 03/01/2012

Date

q

Authorized Representative:

Address:

The record presented was

qq

Kansas Immunization Record

Other Immunization Record (Specify)

DOCUMENTATIONKCI MAY ONLY BE SIGNED BY A PHYSICIAN (MD/DO), HEALTH DEPT, OR SCHOOL.

LEGAL ALTERNATIVES TO VACCINATION REQUIREMENTS "KSA 72-5209"

KANSAS IMMUNIZATION REQUIREMENTS: Based on age of child as of September 1 of current school year.

As per Kansas Statute 72-5209, all children upon entry to school must be appropriately vaccinated. In each column below, vaccines are required for all ages listed in that column.

Ages 0-4

Recommended Schedule

Birth

2 Months

4 Months

6 Months

12-15 Months

HEP B

DTaP/DT

POLIO

HIB

PCV

ROTAVIRUS

DTaP/DT

POLIO

HEP B

HIB

PCV

ROTAVIRUS

MMR

VAR

HIB

PCV

HEP A

DTaP/DT

POLIO

HEP B

HIB

PCV

ROTAVIRUS

Ages 5-6 Ages 7 and Older

DTaP: 5 Doses

a)

b)

c)

POLIO - Grade K-1

† - The ACIP Schedules may be accessed at: http://www.cdc.gov/vaccines/recs/schedules

Vaccine doses given up to 4 days before the minimum interval or age may be considered valid.

With the exception of Hepatitis B vaccine, immunizations given before 6 weeks of age are not considered valid.

Half doses or reduced doses of vaccine are not considered valid.

PARENTS AND/OR GUARDIANS ARE NOT AUTHORIZED TO COMPLETE KCI FORMS.

A ROSTER WITH THE NAMES OF ALL EXEMPT STUDENTS SHOULD BE MAINTAINED. PARENTS OR GUARDIANS OF EXEMPT CHILDREN SHOULD BE INFORMED THAT

THEIR CHILDREN SHALL BE EXCLUDED FROM SCHOOL IN THE EVENT OF AN OUTBREAK OR SUSPECTED CASE OF A VACCINE-PREVENTABLE DISEASE.

KCI FORM B - MEDICAL EXEMPTION is located at http://www.kdheks.gov/immunize/imm_manual_pdf/KCI_formB.pdf

BLANK VERSION OF KCI FORM is available at http://www.kdheks.gov/immunize/download/KCI_Form.pdf

Recommendations are based

on the ACIP recommended

schedule.†

a)

b)

MMR: 2 Doses

a)

b)

c)

d)

VARICELLA: 2 Doses Grades K-3 for 2012-2013 school year

a)

b)

c)

HEPATITIS B: 3 Doses

a)

b)

c)

d)

HEPATITIS B: 3 Doses

a)

b)

c)

d)

VARICELLA: 2 Doses Grades 7-8 for 2012-2013 school year

1 Dose Grades 4-6 and 9-12 for 2012-2013 school year

a)

b)

MMR: 2 Doses

a)

3 Doses

a)

4 Doses

POLIO - All IPV or OPV Schedule

a)

b)

c)

d)

e)

f)

Tdap/Td: 3 doses if no history of any DTaP doses

POLIO - IPV/OPV Combination Schedule: 4 Doses

a)

a)

b)

4 week minimum interval between first 3 doses; 6 month interval between dose 3 and

dose 4.

4 doses acceptable if dose 4 given on or after the 4th birthday.

If dose 4 administered before 4th birthday, 5th dose must be given at 4-6 years of

age.

4 week minimum interval between first 3 doses; 6 month interval required between

dose 3 and dose 4; one dose after 4th birthday

3 doses acceptable if 4 weeks between dose 1 and 2; 6 months between dose

2 and 3; one dose after 4th birthday

First dose on or after the 1st birthday.

4 week minimum interval between doses.


Second dose must be given at least 28 days after first dose.

None required if prior varicella disease verified by physician.

Two doses are recommended for all children.

4 week minimum interval between dose 1 and dose 2.



Dose 3 must be given after 24 weeks of age.


6 month interval between dose 2 and dose 3.

One dose must be Tdap in the series.

Single dose of Tdap required for incomplete DTaP series if age 7 years

or older.

Tdap required for grades 7-10 regardless of interval of last Td.

Tdap required for grades 11-12 if more than 10 years since previous DTaP.

4 week minimum interval between doses, regardless of age given.

4 week minimum interval between each dose, with 1 dose given on or after the 4th

birthday.

4 week minimum interval between doses, regardless of age given.


4 week minimum interval between doses.


Second dose must be given at least 28 days after first dose.

None required if prior varicella disease verified by physician.

Two doses are recommended for all children.

DTaP/DT15-18 Months

POLIO - IPV/OPV Combination Schedule: 4 Doses required

a)

b)




Dose 3 must be given after 24 weeks of age.

4 week minimum interval between first 3 doses; 6 month interval required between

dose 3 and dose 4; one dose after 4th birthday

3 doses not acceptable with combination schedule

USD 385 DEPARTMENT OF HEALTH SERVICES

ANDOVER, KANSAS

IMMUNIZATION STATEMENT Please sign and return with enrollment forms.

Name of Student: _________________________________________ Date of Birth: _____________________________________________

I have been notified that Kansas Law (K.S.A. 72-5208, 72-5209, 72-5210, 72-5211 and 72-5211a) requires every pupil enrolling in any school for the first time, prior to admission, to present proof from a physician or local health department that the pupil has received such tests and inoculations as are deemed necessary.

In USD 385, proof of each inoculation received must be presented prior to admission. Also, mandatory booster inoculations in all required series must be received (within 30 days for students admitted after September 1). If transferring into USD #385, it is the parents obligation to make sure proof of inoculations are received within 30 days. Required inoculations include the following:

DTP, DTaP and/or DT/Td Additions for Early Childhood OPV or IPV Hib MMR PCV7 (pneumococcal) Hepatitis B Hepatitis A Varicella

Parents will be notified of any additional requirements.

Parent/Guardian Signature Indicating Receipt of Notice:

_______________________________________Date:_________________ Student is transferring from: _____________________________________ Name of School City St.

Date Student Entered USD #385: _______________________________

Name: Preferred Contact Number:

Semester 1 Semester 2

Health Opportunities / Physical Education

(required for Graduation)

Health Opportunities / Physical Education


Math

(list) ___________________________

Math

(list) ___________________________

English 9 or English 9 Honors

(circle)


(circle)

Earth Space Science or Honors Earth Space Science (circle) Earth Space Science or Honors Earth Space Science (circle)

World Geography World Geography

Computer Applications


Elective

(list)__________________________

Elective

(list)__________________________

Elective

(list)__________________________

1. Pre-Algebra 4. Algebra 2 or Liberal Arts Math or Business Math

2. Algebra 5. Advanced Math

3. Geometry

College bound seniors are encouraged to consider college release or dual credit options.

Recommended FRESHMAN Selections

Math Progression ( 3 credits beyond Pre-Algebra in high school required)

A four-year planner is included to help in your decisions.

If you have questions please call or e-mail school. We will be here all summer to assist you.

A complete copy of the Enrollment Guide with graduation requirements, course descriptions and additional electives can be

found at www.andoverecademy.org under the "curriculum" tab.

Please mail, fax or email the completed form to:

Please complete this form by circling or listing your choices where indicated.

1413 N. Main St. Andover, KS 67002 Fax: 316-733-4716 email: [email protected]



Math

(list) ___________________________

Math

(list) ___________________________


(circle)


(circle)

Biology or Honors Biology

(circle)

Biology or Honors Biology

(circle)

World History or Honors World History

(circle)

World History or Honors World History

(circle)

Elective

(list)__________________________

Elective

(list)__________________________

Elective

(list)__________________________

Elective

(list)__________________________

Elective

(list)__________________________

Elective

(list)__________________________



3. Geometry


Recommended SOPHOMORE Selections











Math

(list) ___________________________

Math

(list) ___________________________


(circle)


(circle)

Chemistry or Honors Chemistry

(circle)

Chemistry or Honors Chemistry

(circle)

U.S. History or Honors U.S. History

(circle)

U.S. History or Honors U.S. History

(circle)

Fine Arts

(list) ___________________________

Fine Arts

(list) ___________________________

Elective

(list)__________________________

Elective

(list)__________________________

Elective

(list)__________________________

Elective

(list)__________________________



3. Geometry


Recommended JUNIOR Selections











Math - optional if 3 credits are earned or elective

(list) ___________________________

Math - optional if 3 credits are earned or elective

(list) ___________________________

English 12 or AP English

(circle)

English 12 or AP English

(circle)

Science - optional if 3 credits are earned or elective

(list) ___________________________

Science - optional if 3 credits are earned or elective

(list) ___________________________

Government or Honors Government

(circle)

Speech


Credit Recovery

(list)__________________________

Credit Recovery

(list)__________________________

Credit Recovery

(list)__________________________

Credit Recovery

(list)__________________________

Credit Recovery

(list)__________________________

Credit Recovery

(list)__________________________



3. Geometry


Recommended SENIOR Selections









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