Enrollment Forms Packet (EFP)

Required For? Item Description Provided by?

Required for all Students

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

Proof of Residency Current Utility bill showing service address OR Mortgage statement/Rental con-tract including signature page OR recent tax statement Provided by you

Immunization Record Current Immunization Record Provided by you

Report Card The most recent Report Card Provided by youSocial Security Card Please note do not send actual card, please submit a copy. Provided by you

Home Language Survey Complete this form and submit. Provided in this

packet

Migrant Student Survey Complete this form and submit. Provided in this

packet

Ethnicity Data Questionnaire Please write your student’s name, as it was entered on the application. Provided in this

packet

Release of Records

By filling out this form, you are giving our school permission to request your student’s official records from their previous school after the approval process. If your child was Homeschooled please indicate it on the form, fill out the top por-tion and sign it.

Provided in this packet

Withdrawal Intent Form Complete this form and submit. Provided in this

packet

Required for student with an IEP or other Special Education needs

IEP A copy of your student’s current IEP (Individualized Education Plan). Because the IEP expires yearly, please submit the current IEP. Provided by you

Evaluation Report The Evaluation Report is valid for 3 years. If you do not have a copy of your student’s ER, you can request a copy from your student’s current school. Provided by you

Required for students that have a 504 plan

504 Accommoda-tion Plan

A copy of your student’s current 504 Accommodation Plan. Because the 504 expires yearly, please submit the current 504. Provided by you

Please review the information below. Based on your student(s) grade and applicable circumstances, you are required to sub-mit documentation in order to complete this step in the enrollment process. You can fax, scan and email, or mail the required paperwork .

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

Fax (preferred): Scan and Email: Mail: 1-877-257-4612 txvafax@k12.com Texas Virtual Academy 104 Industrial Blvd B-2 Sugarland, TX 77478

v1.1

Texas Virtual Academy @ SouthwestEnrollment Processing Center104 Industrial Blvd, B-2Sugar Land, TX 77478

Ph. 877.554.1084Fx. 877.257.4612www.txva.org

Texas Virtual Academy @ SouthwestEnrollment Processing Center104 Industrial Blvd, B-2Sugar Land, TX 77478

Ph. 866.360.0161Fx. 877.257.4612www.txva.org

Student InformationStudent’s Full Name:

first middle last

Student’s Date of Birth:

Student’s Legal Address: street apt #

city county state zip

Home Phone:

Check below if applicable:

o Student was always previously homeschooled

o Student is enrolling in Kindergarten

Name of Prior School:

School’s Address: street

city county state zip

School’s Phone: School’s Fax:

Name of Parent or Legal Guardian: first last

Parent/Guardian’s Signature: Date:

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

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

Prior School Information

Sign and Date below

SCHOOL OFFICIALS ONLY:

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

SCHOOL OFFICIALS ONLY:

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

SCHOOL OFFICIALS ONLY:

Send student records to: Texas Virtual Academy @ Southwest 104 Industrial Blvd, B-2 Sugar Land, TX 77478

Student’s Name: Student’s Home Phone:

Southwest School 3333 Bering Drive Houston, TX 77057 ▪ Phone 713-784-6345

HOME LANGUAGE SURVEY Home Language Survey

Encuesta a Sobre el Idioma del Hogar (PK-12) Student's Name: ________________________________________ School:__________________________________________ Nombre del alumno Escuela Student’s Address: ______________________________________ Home Phone _____________________________________ . Domicilio Telefono de Casa Date of Birth: __________________________________________ Grade: ____________ ID: _________________________ Fecha de nacimiento Month Day Year

Mes Dia Ano The Texas Education Code requires schools to determine the language(s) spoken at home by each student in order to provide an appropriate program of instruction. Please answer the following questions to help place your child in the most appropriate instructional program. El Codigo de Educacion de Texas requiere que las escuelas determinen el idioma que se habla en el hogar para identificar o proporcionar la instruccion apropiada para cada estudiante. Por favor conteste las siguientes preguntas para que podamos ayudarle a su hijo(a) en el programa mas apropiado. Place of Birth (Country of Origin) Date of initial entry into U.S. schools Lugar de nacimiento del estudiante Fecha en que el estudiante empezo sus

estudios en los Estados Unidos

_______________________________________ _____________________________________________ City/Ciudad Country/Pais Month/Mes Day/Ano Year/Ano Has your family moved within the last 36 months to seek or do temporary work? Number of academic years completed in a U.S. school

Nurnero de anos escolares que ha completado el estudiante en los Estados Unidos _____________________

Se ha mudado usted o un miembro de su familia en los ultimos 36 meses para buscar o hacer trabajo temporal? __________ Yes __________ No

1. What Language is spoken in your home most of the time? Cual idioma se habla en su hogar la mayoria del tempo? __________ English ______________ Spanish __________ Other (Specify)

Ingles Espanol Otro (Favor de especifcar

2. What language does your child speak most of the time? Cual idioma habla su Hijo(a) la mayoria del tiempo?

__________ English ______________ Spanish __________ Other (Specify)

Ingles Espanol Otro (Favor de especifcar ___________________________________________ _______________________________ Parent or Guardian/Firma del Padre(s) o guardian Date/Fecha

FOR OFFICE USE ONLY / Solo para el uso de la oficina Note to school personnel:

1. File original of the Home Language Survey (HLS) in student’s folder. 2. Send copy of the Home Language Survey (HLS) to the Bilingual/ESL Coordinator on the day the student enrolls.

MIGRANT STUDENT SURVEY

ENCUESTA PARA MIGRANTES Dear Parent, Your children may qualify for supplemental services at Southwest School if they meet certain qualifications. To help us, please answer the following questions. Sus ninos pueden ser elegibles para servicios educacionales suplementarios en su distrito escolar si tienen cietos requistos. Para ayudarnos, por favor, conteste las siquientes preguntas. Student’s Name:___________________________________________________

1. Has your family moved any time during the last three years from one school district to another in Texas or across the state? Yes ____________ No _____________ ¿ Ha cambiado de Distrito Escolar durante los años passados?

2. Were any of these moves made to find temporary or seasonal work in agriculture related to a job in packing,

processing, harvesting, cultivating of crops, food processing, dairy work, forestry, fishing, etc? Yes __________ No _____________ Estos cambios fueron para buscar trabajo temporal en cualquiera de las siguientes industrias como en agricultura. empacadora, procesando, cultivando, o levantando cosechas, etc. Tambion procesando comida, trabajo de lecheria, trabajo forestall, o trabajo de pesca? Yes ___________ No ___________

If you answered “yes” to question # 2, please complete the information below.

Name of parent or guardian: ________________________________Phone # ______________________________

Address/ city/ zip_____________________________________________________________________________ Si contesta si a la pregunta # 2, por favor complete la informacion siguiente.

Nombre del padre o guardian: _______________________________ Telefono: ______________________

Direccion: __________________________________________________________________________________

Also list names and ages of children who are not enrolled in school.

Por favor escriba nombres y edades de su hijo/ a que no edtan en la escuela.

Age Last Name First Name Middle Name (Edad) (Apellido (Nombre) Segundo nombre)

_______________ ________________________ _______________________ ___________________

_______________ ________________________ _______________________ ___________________

_______________ ________________________ _______________________ ___________________

_______________ ________________________ _______________________ ___________________

Thank you (Gracias) PARENT’S SIGNATURE: ____________________________________DATE: ________________________ (Firma de los padres) (fecha)

104 Industrial Blvd, B-2, Sugar Land, TX 77478, Ph. 877.554.1084, Fx. 877.257.4612, www.txva.org SY 2010-2011

WITHDRAWAL INTENT FORM

If I, _____________________ (parent/guardian) should decide that TXVA is not

the appropriate place for my student ______________________, my preferred

educational intent to school will be the following:

Home School

Private School

*Name of Public School (if this is the choice, this information must be

completed and is not optional):________________________________________

Address: _________________________________________________________

Phone Number: _______________________________ *Responsibility for compliance with state attendance statutes and regulations belongs to the

parents, but the school is obligated to keep an accurate record of daily attendance. By statute,

if a student is not meeting the statutory requirements for public school attendance, the student

is considered truant under TEC 25.094.

This statute defines truancy as:

*not being in attendance 10 or more days within a six-month period and/or

*not being in attendance 3 or more days within a 4-week period

As a truant student:

1. The student's parent or legal guardian is subject to prosecution under Texas

Education Code 25.093.

2. The student is subject to prosecution under Texas Education Code 25.094. A fine of

$500.00 may be assessed.

Print Parent/Guardian Name: ______________________________

Parent/Guardian Signature: ____________________________________ Date: _____________