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Wickenburg Virtual Academy Enrollment Packet
Wickenburg Virtual Academy
Enrollment Packet
WICKENBURG UNIFIED SCHOOL DISTRICT #9 REGISTRATION FORM
Student Name Nombre del estudiante Last/apellido First/nombre Middle/medio Other Name or Nickname/apodo
Sex/Sexo: M F Grade Level/grado Age/edad Birthdate/nació
Place of Birth/lugar donde nació City/ciudad State/estado Country/pais
Birth Certificate/acta de nacimiento Yes/Sí No Residing County/vive en condado
Physical Address / dirección
Mailing Address / dirección del correo (if different / si diferente)
Home Phone Number /teléfono de
casa
Cell Phone / cellular
Has this student ever attended a school in Arizona?
Este estudiante ha asistido siempre a una escuela en Arizona? Yes/Sí No
Number of Years in U.S. Schools
Número de años en escuelas de U.S.
________
Has this student ever attended a school in the Wickenburg School District?
Este estudiante ha asistido siempre a una escuela en el distrito de Wickenburg? Yes/Sí No
Do you have other children attending schools in the Wickenburg District?
¿Tiene otros hijos en las escuelas de el distrito de Wickenburg? Yes/Sí No
Has this Student been enrolled in any of the following programs? ¿Ha asistido este estudiante a uno de estos programas?
Special Education/educación especial ____ Gifted/talentoso ____ Speech/terapeuta de lenguaje ____ ELL ____ Title 1/título 1____
Student Lives with Relationship
Estudiante vive con Names/nombres relación al estudiante
Parent/Guardian’s Name
Nombre de padre o guardian Last / apellido First / nombre Middle / medio
Employer/empleo
Work Phone / teléfono
Spouse’s Name
Nombre de la esposa Last / apellido First / nombre Middle / medio
Employer/empleo
Work Phone / teléfono
Emergency Contact Name and Numbers En caso de la emergencia con exepción de los padres ¿a quién debemos de llamar?
Name / Nombre Phone Number / teléfono Relationship / relación al estudiante
1.
2.
Signature of Parent or Guardian / firma Date / fecha
FOR OFFICIAL USE ONLY / PARA EL USO OFICIAL SOLAMENTE
Below, please indicate one of the following codes: 1. English 2. Spanish 3. American Indian 4. Other
Por favor utilice estos numeros para completer los espacios sigientes. 1. Inglés 2. Español 3. Indio Americano 4. Otro
1. What is the primary language used in the home regardless of the language spoken by the student? ¿Cuál idioma se habla
principalmente en su hogar sin considerar el idioma que habla el estudiante? __________
2. What is the language most often spoken by the student? ¿Cuál idioma habla el estudiante con mayor frecuencia?__________
3. What is the language that the student first acquired? ¿Cuál fue el primer idioma que aprendió el estudiante?__________
Ethnic / la raza _____ 1. White/blanco 2. Black/negro 3. Hispanic/hispáno 4. American Indian/indio 5. Pacific Islander/isleño
Counselor ______________________________ Transportation: Walk ________ Bus ________ Bus # ________
Home Room Number _________ Home Room Teacher _________________________________________________
Tuition District _____________________ Entry Date _____________ Entry Code _________ Attn: Reg _________ Load _______
Wickenburg Virtual Academy Application
Welcome to Wickenburg Virtual Academy. Please complete all parts of form, including required signatures before submitting this form. Mail this form to: 1090 S. Vulture Mine Rd., Wickenburg, AZ 85390 or Fax to: 928-684-6628. You may also choose to scan the application along with residency documentation & email it to: [email protected] Student Name: Last____________________________First________________________________Middle Initial________ Date of birth: _____________ Grade Level _____ Male Female Student I.D. #_______________ Parent/Guardian Name: Last ____________________________ First________________________Middle Initial ________ Mailing Address: _______________________________________City____________________State_____Zip Code_________ Physical Address: ______________________________________ City ____________________State_____Zip Code ________ Parent/Guardian: Home Phone _______________ Cell Phone _______________ Parent Email ________________________ Student Cell Phone: __________________________ Student Email____________________________________ Below, please indicate one of the following number codes: 1.English 2. Spanish 3. American Indian 4. Other
Student’s first acquired language/idioma para hablar primaro al estudiante ______
Language spoken by student most often/idioma habla mas frecuentemente el estudiante _______
Language spoken at home most often by the family/idioma habla mas frecentemente la familia en casa ________ Ethnicity/la raza ______ 1. White/blanco 2. Black/negro 3. Hispanic/Hispanico 4. American Indian/indio 5. Pacific Islander/isleno
Has this student ever attended a school in Arizona? _________ Number of years in U.S. Schools? ____________ Has this student ever attended a school in the Wickenburg School District: Y or N Do you have other children attending schools in the Wickenburg School District? Y or N Has this student been enrolled in any of the following programs? Special Education ______ Gifted _____ Speech _____ SEI/English Language Learner _____ Title 1 Reading or Math _____ Emergency Contact Name & Numbers:
1. _________________________________ Phone: ____________________ Relationship: ___________________
2. _________________________________ Phone: ____________________ Relationship: ___________________
Online Education Compatibility:
1. Does student have weekly access to a computer, with high speed internet, for 25+ hours per week? Y or N 2. Does student have the ability to discipline herself/himself, to focus on work, and learn independently? Y or N 3. Student & Parent understand that both of them must sign student work logs verifying hours per week. Y or N
Signature of Parent or Guardian: _________________________________________________________Date: ______________
Wickenburg Unified School District #9
Wickenburg Virtual Academy 1090 S. Vulture Mine Road
Wickenburg, AZ 85390
Phone: 928-684-6717 FAX: 928-684-6628
Students entering Wickenburg Virtual Academy must provide the following documents. Please bring these items when you
register. Missing items can delay the enrollment process. This information will be kept confidential and will be located in
the Records Office. If you have any questions please let us know how we may assist you.
___ Attendance Area Verification
Current electric or gas bill with parent/guardian name and address OR
Current purchase agreement in parent/guardian name OR
Closing Statement OR
Rental/Lease Agreement indicating address, terms and occupants names
___Birth Certificate
Original State issued birth certificate. (A hospital certificate is unacceptable)
Legal name change documentation must be provided if attempting to register by name other than provided on the
original birth certificate.
___Current Photo ID of Registering Parent/Guardian
Driver’s License OR
State Photo ID
___Custody or Guardianship Documents (required even if you share Joint Custody)
Divorce decree naming Petitioner/Respondent, indicating custodial parent and include official signature pages OR
Court Ordered Guardianship naming guardians and providing address where student will reside OR
CPS Placement providing residential address and name of authorized caretakers
If non-custodial parent is registering student, custodial parent will authorize non-custodial parent to make all
medical and educational decisions for the student while enrolled at WVA by way of a notarized document.
___Death Certificate
If biological parent is deceased
___Immigration Papers
Copy of current J-94
___Immunization Documentation
Current immunization records required
___Marriage License
Required if parent name change from original birth certificate
Required if guardian name change from original custody documents issued
___School Records
Transcript – unofficial is acceptable for registering
Withdrawal for – required if registering during current schoolyear
Certificate of Promotion – required information for incoming freshmen
Testing Scores – Standardized test scores, Stanford 9, Phlote Scores
Special Education Records – Current IEP, Psychological reports
___Athletics
Did you play any sports from your previous school? Y N
Do you plan on playing in any sports? Y N
Wickenburg Virtual Academy
1090 S. Vulture Mine Road
Wickenburg, AZ 85390
Phone: 928-684-6717 FAX: 928-984-6628
REQUEST FOR RECORDS
Date:
Previous School
School
Address:
City State Zip
Student Name: DOB: Grade:
The above student has enrolled at the Wickenburg Virtual Academy. Please forward the
following records to us at your earlies convenience.
1. Transcript of grades and credits
2. Withdrawal grades
3. Explanation of your grading system
4. Heath and immunization records
5. Discipline records
6. Academic test scores
7. AIMS test results
8. IEP/Special Education Records
9. Cumulative File
Parent/Guardian Signature
Thank you,
Rose Garcia, M.Ed.
928-684-6715
#2306606
Arizona Department of Education Arizona Residency Documentation Form
Student School
School District or Charter Holder _____________________________________________
Parent/Legal Guardian
As the Parent/Legal Guardian of the Student, I attest that I am a resident of the State of Arizona and submit in support of this attestation a copy of the following document that displays my name and residential address or physical description of the property where the student resides:
___ Valid Arizona driver’s license, Arizona identification card or motor vehicle registration ___ Valid U.S. passport ___ Real estate deed or mortgage documents ___ Property tax bill ___ Residential lease or rental agreement ___ Water, electric, gas, cable, or phone bill ___ Bank or credit card statement ___ W-2 wage statement ___ Payroll stub ___ Certificate of tribal enrollment or other identification issued by a recognized Indian tribe that
contains an Arizona address. ___ Documentation from a state, tribal or federal government agency (Social Security Administration,
Veteran’s Administration, Arizona Department of Economic Security) ___ I am currently unable to provide any of the foregoing documents. Therefore, I have provided an
original affidavit signed and notarized by an Arizona resident who attests that I have established residence in Arizona with the person signing the affidavit.
__________________________________ ________________
Signature of Parent/Legal Guardian Date
Wickenburg Unified School District #9
Rights of McKinney-Vento Eligible Students and Families
If your living arrangement is both temporary and the result of economic hardship, you may qualify
for services under the McKinney-Vento Act. The purpose of this law is to provide academic
stability for students of families in transition.
You may want to talk with the Wickenburg Unified School District Homeless Liaison or your
child’s counselor if your family’s living arrangements is any of the following.
You are living with friends or relatives, or moving from place to place, due to economic
hardship
You are living in a shelter or a motel
You are living in a substandard housing, possibly without water or electricity
You are living in a place not considered traditional “housing”, such as a car or a
campground.
* A student may also qualify as an unaccompanied youth if he or she is living with someone
who is not a parent or guardian or if he or she is moving from place to place without parent
or guardian. This includes runaways and students who can’t return home due to violence
in the household.
Children who qualify under McKinney-Vento have the right to:
Attend the school they were last enrolled at the time of instability in the family’s living
situation, even if that school is in another district. The choice must be a reasonable one
that is in the best interest of the children involved. Check with the Homeless Liaison for
additional information.
Receive assistance with transportation to attend school while they are being temporarily
housed if requested by the family and found feasible by the district.
Start school immediately while school personnel assist families with obtaining school and
immunization records or other documents necessary for enrollment.
Receive the same special programs and services, if needed, as provided to all other children
or youths served in these programs – Title 1, ELL, Special Ed., etc.
Receive free breakfast and lunch.
Determinations will be made on a case by case basis. If you are eligible for assistance as described
in the McKinney-Vento Act, you will be notified by your school counselor. If you do not qualify,
you will receive written notice and receive directions regarding the dispute process.
If you have questions, call Amy Monesmith at 928-684-6710 or 928-501-6006
or email her at [email protected].
EMERGENCY MEDICAL INFORMATION
Student Name _________________________________________ Graduation Year___________
Date of Birth_________________
Does your child have a history of (or currently have) any of the following conditions?
Yes No
Chicken Pox ____ ____
Asthma ____ ____
Diabetes ____ ____
Medical conditions ____ ____ please describe below.
Allergies ____ ____
Medication ____ ____
Bee stings ____ ____
Scorpions ____ ____
Latex ____ ____
List any and all allergies: ________________________________________________________________________
Medical Conditions:___________________________________________________________________________
___________________________________________________________________________________________
Would you like to discuss any of your child’s health history with school personnel? Yes ___ No ___
Phone # __________________
I give my permission for my child to take Acetaminophen/Tylenol (Non Aspirin pain reliever) Yes___ No__
If any over the counter or prescription medicine is needed, a parent must provide medicine in a sealed, un-opened
container. All prescription medication must be in its original bottle from the pharmacy.
Signature of Parent/Guardian ______________________________________ Date___________________
Maricopa County Department of Public Health
Office of Community Health Nursing 602-506-6767 www.maricopa.gov chickenpoxletter-2012
Chickenpox Status Form (Varicella)
Dear Parent: ___________________________ Date:___________________
Beginning September 1, 2011 students entering school in AZ for the first time
need to meet one of the conditions listed below:
Proof of varicella immunization
Valid medical exemption from physician office
Laboratory evidence of immunity to chickenpox
Personal beliefs exemption
The Arizona Department of Health Services ( ADHS) following the Centers for
Disease Control and Prevention (CDC) guidelines has required compliance with
this vaccine (shot) requirement. Please review your student’ record and check the
correct box below and then bring this letter and your student’s vaccination record
to your school health officer prior to the beginning of the school year.
Student’s Name: ___________________ Date of Birth: ________________
Parent Signature: ____________________ Date: ___________________
You need to give this information to your school. Complete this form and bring it to your
student’s school health officer.
**This new ruling does not apply to students who have been attending school in Arizona
prior to September 1st
2011.
Thank you for your cooperation
__Yes, my child has had chickenpox Proof to be obtained from physician letter or blood test (titer)
___Yes, my child received the chickenpox vaccine. Submit vaccine date to school staff
_ No, my child has never had the illness or vaccine for chickenpox Please obtain the vaccination
__I will ask the school health staff regarding obtaining a personal belief exemption for varicella
If you need vaccinations, please contact your private provider or call Community Information
and Referral at 602-263-8856, 800-352-3792 or find them on the web at www.cirs.org
___ Yes, my student has had the chickenpox Shot\Vaccine**
___ No, my student has not had chickenpox. Please obtain the vaccination immediately.
If you need vaccinations, please contact your private provider or call Community Information and
Referral at 602-263-8856, 800-352-3792 or find them on the web at www.cirs.org
___ No, my student has not had EITHER the chickenpox disease or the vaccination. **
**Please note that prior vaccination exemption release forms DO NOT include
chickenpox\varicella. Please contact your school health office to file the appropriate form.
Wickenburg Virtual Academy
Dear Parent/Guardian:
By signing below, you are stating the following:
Please read all information below and sign an agreement. If for any reason you do not agree to permission for Student Field Trips, Photo Permission, Transportation Authorization, Connect Ed Announcements, Electronic Usage rules and regulations, then please submit a written document.
Photo Release: Pictures of students and staff can be taken throughout the school year for various reasons such as the yearbook or perhaps a newspaper article covering an activity here at the school. We are asking all parents/guardians to sign this waiver so your child’s phot may be used for the yearbook, newspaper and school board reports. By signing this release you are giving the school your consent to take and use your child’s photo for these purposes.
Electronic Use, Acceptable Use: Each user must: o Use the Electronic Information Services (EIS) to support personal educational objectives consistent with
the educational goals and objectives of Wickenburg Unified School District. o Agree not to submit, publish, display or retrieve any defamatory, inaccurate, abusive, obscene, profane,
sexually oriented, threatening, racially offensive or illegal material. o Immediately inform their teacher if inappropriate information is mistakenly accessed. o Abide by all copyright and trademark laws and regulations. o Not reveal home addresses, personal phone numbers or personally identifiable data unless authorized to
do so designated school authorities. o Understand that electronic mail or direct electronic communication is not private and may be read and
monitored by school employed persons. o Not use the EIS in any way that would disrupt the use of the EIS by others. o Follow the District’s code of conduct. o Not attempt to harm, modify, add or destroy software or hardware nor interfere with System security. o Understand that inappropriate use may result in cancellation of permission to use the EIS and appropriate
disciplinary action up to and including expulsion. o Be responsible for the appropriate storage and backup of their data.
The Wickenburg School District specifically denies any responsibility for the accuracy of information. While the District will make an effort to ensure access to proper materials, the user has the ultimate responsibility for how the electronic information services is used and bears the risk of reliance on the information obtained.
I understand and will abide by the provisions and conditions indicated. I understand that ay violations of the above terms and conditions may result in disciplinary action and revocation of my use of information services. As the parent or guardian of the above named student I have read this agreement and understand it. I understand that it is impossible for the School District to restrict access to all controversial materials and I will not hold the District responsible for materials acquired by use of the EIS. I also agree to report any misuse of the EIS to a school district administrator. (Misuse may come in many forms but can be viewed as any messages sent or received that indicate or suggest pornography, unethical or illegal solicitation, racism, sexism, inappropriate language or other issues described in the agreement.).
I accept full responsibility for supervision if and when my child’s use of the EIS is not in a school setting. I hereby give my permission to have my child use the Electronic Information Services (EIS).
Field Trips: There are times during the school year when classes are taken on field trips. It is necessary for each student to have parental permission to attend. No student is allowed to attend without a permission slip. You will be sent a written notification prior to each field trip with information regarding each field trip. We are asking that you give permission at this time for any field trips planned during the school year.
Student Transportation: I have read and understand the school bus rules and regulations located in the student handbook. My student has my permission to use the school bus transportation to and from school or in the event of a scheduled field trip. According to state law the responsibility to get each student to and from school rests with the parent. As a courtesy, Wickenburg Unified School District attempts to provide free bus service to students within district boundaries. We want each student to have a safe and enjoyable trip while on the school bus. Any changes in student scheduling to ride the school bus must be accompanied by written authorization from the parent/guardian.
Connect Ed Announcement Communication System: Please indicate which phone numbers and e-mail addresses you want us to use when contacting you through Connect Ed Announcements on the lines provided below. Note: Emergency messages will out to ALL available numbers.
Home Phone #: E-mail Address:
Mother’s Day Phone:
Mother’s Cell Phone for Texting:
Father’s Day Phone:
Father’s Cell Phone for Texting:
Emergency Care Consent: If an emergency involving medical action is required and the parents or guardians cannot be contacted, I consent for my child to be given medical attention by the doctor selected by the school personnel in charge. Please lest family physician and insurance information below.
Name of Physician: Phone Number:
Insurance Company:
Policy Number:
Print Student Name:
Student Signature:
Print Parent/Guardian Name:
Parent/Guardian Signature:
Technology Use Agreement 2/22/11
Wickenburg Unified School District 40 West Yavapai Street Wickenburg, AZ 85390
Phone: 928-668-5350 FAX: 928-668-5390 www.wickenburgschools.org
USE OF TECHNOLOGY RESOURCES IN INSTRUCTION
ELECTRONIC INFORMATION SERVICES STUDENT USER AGREEMENT
When the signed agreement is returned, the user may be permitted use of electronic information services (EIS) resources.
Terms and Conditions
Acceptable Use: Each user must:
Use the EIS to support personal educational objectives consistent with the educational goals and objectives of the
Wickenburg Unified School District.
Agree not to submit, publish, display, or retrieve any defamatory, inaccurate, abusive, obscene, profane, sexually oriented,
threatening, racially offensive, or illegal material.
Immediately inform their teacher if inappropriate information is mistakenly accessed.
Abide by all copyright and trademark laws and regulations.
Understand that electronic mail or direct electronic communication is not private and may be read and monitored by school-
employed persons.
Follow the District’s code of conduct.
Understand that inappropriate use may result in cancellation of permission to use the EIS and appropriate disciplinary action
up to and including expulsion.
Be responsible for the appropriate storage and backup of their data.
Unacceptable Uses:
Users may not connect or install any computer hardware, hardware components, or software, which is their own personal
property to and/or in the District’s EIS without the prior approval of the District Information Technology Department.
Users shall not post information that could cause damage or pose a danger of disruption to the operations of the EIS or the
District.
Users will not reveal home addresses, personal phone numbers or personally identifiable data unless authorized to do so by
designated school authorities.
Users will not use the EIS in any way that disrupts the use of the EIS by others.
Users will not use the EIS for commercial or financial gain, political lobbying, or fraud.
Users will not attempt to harm, modify, add, or destroy software or hardware.
Users will not interfere with system or network security.
Users shall not access the network for any non-educational purposes.
Users will not gain or attempt to gain unauthorized access to the files of others, or vandalize the data or files of another user.
Users will not download and use games, files, documents, music, or software for non-educational purposes. (i.e., Shockwave
games/animations, audio and other visual files).
Users will not possess any data, which may be considered a violation of these regulations, in paper, magnetic (disk), or any
other form.
Users will not display name or photo to personally identify an individual without receiving written permission.
Users will not reveal full name, address, phone number, or personal email without permission from an adult.
Users shall not plagiarize work that is found on the internet or any other electronic resource.
Users will not harass, insult, attack others, or use obscene language in written communications.
Users will not post anonymous messages.
Users may not use free web based email, messaging, video conferencing, or chat services without written permission from
the District Information Technology Department.
Resource Limitations:
Activities that are deemed by the network supervisor to cause unreasonable demand on network capacity or disruption of
system operation are prohibited.
Technology Use Agreement 2/22/11 2
Wickenburg Unified School District 40 West Yavapai Street Wickenburg, AZ 85390
Phone: 928-668-5350 FAX: 928-668-5390 www.wickenburgschools.org
Users shall subscribe only to high quality discussion groups or mailing lists that are relevant to their educational or career
development.
Users shall not use the District’s EIS for commercial purposes or financial gain. This includes the creation, development and
offering of goods or services for sale, and the unauthorized purchase of goods or services. District approved purchases will
be made following District approved procedures.
The District’s portable information systems and educational technology resources such as notebook computers, peripherals,
and/or companion devices, will be at the school sites during school hours.
Personal responsibility: I will report any misuse of the EIS to the administration, as is appropriate. I understand that many services
and products are available for a fee and acknowledge my personal responsibility for any expenses incurred without District
authorization.
Network etiquette: I am expected to abide by the generally acceptable rules of network etiquette. Therefore, I will:
Be polite and use appropriate language. I will not send, or encourage others to send, abusive messages.
Respect privacy. I will not reveal any home addresses, or personal phone numbers, or personally identifiable information.
Avoid disruptions. I will not use the EIS in any way that would disrupt the use of the systems by others.
Observe the following considerations:
o Be brief.
o Strive to use correct spelling and make messages easy to understand.
o Use short and descriptive titles for articles.
o Post only to known groups or persons
Services:
The Wickenburg Unified School District specifically denies any responsibility for the accuracy of information. While Wickenburg
Unified School District will make an effort to ensure access to proper materials, the user has the ultimate responsibility for how the
EIS is used and bears the risk of reliance on the information obtained.
I understand and will abide by the provisions and conditions indicated. I understand that any violations of the above terms and
conditions may result in disciplinary action and the revocation of my use of information services.
Name (printed) _______________________________________________________Grade___________________________
Signature ____________________________________________________________ Date ___________________________
The user agreement of a student who is a minor must also have the signature of a parent or guardian who has
read and will uphold this agreement.
Parent or Guardian Cosigner
As the parent or guardian of the above named student, I have read this agreement and understand it. I understand that it is impossible
for the Wickenburg Unified School District to restrict access to all controversial materials, and I will not hold the District responsible
for materials acquired by use of the electronic information services (EIS). I also agree to report any misuse of the EIS to a District
administrator. (Misuse may come in many forms but can be viewed as messages sent or received that indicate or suggest
pornography, unethical or illegal solicitation, racism, sexism, inappropriate language, or other issues described in the agreement).
I accept full responsibility for supervision if, and when, my child’s use of the EIS is not in a school setting. I hereby give my
permission to have my child use the electronic information services.
Parent or Guardian Name (printed) ___________________________________________________________________________
Signature _________________________________________________________________ Date __________________________
State of Arizona Department of Education
Office of English Language Acquisition Services
Primary Home Language Other Than English (PHLOTE)
Home Language Survey (Effective April 4, 2011)
These questions are in compliance with Arizona Administrative Code, R7-2-306(B)(1), (2)(a-c). Responses to these statements will be used to determine whether the student will be assessed for English Language Proficiency.
1. What is the primary language used in the home regardless of the language spoken by the student? __________________________________________________________
2. What is the language most often spoken by the student? _______________________
3. What is the language that the student first acquired? __________________________
Student Name ______________________________________ Student ID __________________ Date of Birth _____________________________________ SAIS ID ______________________ Parent/Guardian Signature __________________________________ Date _________________ District or Charter ______________________________________________________________ School _______________________________________________________________________ -------------------------------------------------------------------------------------------------------------------------------------------- Please provide a copy of the Home Language Survey to the ELL Coordinator/Main Contact on site. In SAIS, please indicate the student’s home or primary language.
1535 West Jefferson Street, Phoenix, Arizona 85007 • 602-542-0753 • www.azed.gov/oelas
Estado de Arizona Departamento de Educación
Servicios de Aprendizaje del Inglés
Idioma Principal en el Hogar excluyendo el inglés (PHLOTE) Encuesta sobre el Idioma en el Hogar
(Efectivo el 4 de abril de 2011)
Preguntas en conformidad con R7-2-306(B)(1), (2)(a-c) del Reglamento de la Junta Directiva.
Las respuestas que proporcione a las preguntas siguientes serán usadas para determinar si se evaluará la competencia en el idioma inglés de su hijo(a). 1. ¿Cuál idioma se habla principalmente en su hogar sin considerar el idioma que habla el
estudiante? ________________________________________________________________ 2. ¿Cuál idioma habla el estudiante con mayor frecuencia? __________________________ 3. ¿Cuál fue el primer idioma que aprendió el estudiante? ___________________________ Nombre del estudiante ___________________________ Núm. de identificación _____________ Fecha de nacimiento __________________________ Núm. de SAIS ______________________ Firma del padre o tutor ____________________________________ Fecha _________________ Distrito o Charter _______________________________________________________________ Escuela _______________________________________________________________________ -------------------------------------------------------------------------------------------------------------------------------------------- Please provide a copy of the Home Language Survey to the ELL Coordinator/Main Contact on site. In SAIS, please indicate the student’s home or primary language.
1535 West Jefferson Street, Phoenix, Arizona 85007 • 602-542-0753 • www.azed.gov/oelas
SPECIAL PROGRAM SERVICES INFORMATION SURVEY Parents or guardians of students should complete this form at time of enrollment:
In order to provide continuity in the educational environment, it is important that we are informed
of any special
education services previously received by your child. Please complete the following form and feel
free to add any
comments in the space provided below.
Student Name_____________________________________________________
First Middle Last
Previous School ___________________________________________________
Has your son/daughter ever had any Special Program Services provided for him/her at a
previous school?
____ Yes ____ No
Has your son/daughter ever been tested for Special Program Services while at a previous
school?
____ Yes ____ No
Have you ever signed an individualized Education Plan (IEP) that provides for Special
Program Services for your
son/daughter? ____ Yes ____ No
If yes, please indicate previous school and approximate date the most recent IEP was written
_______________________________________________________________
Has your son/daughter received any special program services in the past but is no longer in
need of these services
____ Yes ____ No
Please check the special programs that your student has participated in: ____ Gifted and honors classes
____ Specific learning disability (tutoring or resource room support)
____ Speech and language therapy
____ Multiple disabilities
____ Orthopedic impairment (Physical or Occupational Therapy or Adaptive PE)
_____ Other health impairment
____ Hearing impairment
____ Visual impairment
____ Emotional disability, self-contained classroom
____ Emotional disability, resource room support
____ Traumatic brain injury
____ Section 504 Accommodation Plan
____ English as Second Language Program/Bi-lingual resource)
____ Other or comments __________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Signature of Parent ______________________________________Date
__________________
ATTENDANCE RECORD (Illustration Purposes – you will receive an Attendance Form for each Session or 9 week period)
For state attendance purposes, we must have you and your parent/guardian send a log of hours worked each week. You will receive a form, with dates for the Academic Block, as shown below. You will need to keep track of time you spent, both online and offline, each week on required assignments. You and your parent will sign the record each week, and fax, mail, or scan a copy to the Principal, Rose Garcia. Failure to do so will be counted as “non-attendance” and you will be withdrawn from the Virtual School if you fail to send these attendance logs in each week. The example below is for a fall grading quarter – but there are sheets for Summer Session I, Fall 1st 9 weeks, Fall 2nd 9 weeks, Spring, 3rd 9 weeks, Spring 4th 9 weeks, & Summer Session II.
Wickenburg Virtual Academy
Fall 2017 - 1st 9 weeks
Fill in the hours per day that you worked online or worked on offline assignments:
Week of: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Hours per
Week Required Hrs./Week
August 7-13 30
August 14-20 30
August 21-27 30
August 28- Sept 3 30
September 4-10 30
September 11-17 30
September 18-24 30
September 25-Oct 1 30
October 2-8 30
Fall Break Oct 9-15 30
Total Hours per week 300 Total
I certify that the hours above are accurate and a true representation of my student's online work through the Virtual Academy.
_________________________________________________________ _____________________________________________________ Student Signature & Date Parent Signature & Date
__________________________________________________________ Wickenburg Virtual Academy Administrator Date
Wickenburg Virtual Academy
Our school’s calendar is different than others in the school district, since we are a year round, twelve month school, built to meet students’ individual needs. Our school year starts in July with Summer Session I, and continues through the traditional school year, and ends with Summer Session II.
Wickenburg Virtual Academy School Calendar
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
July Summer 3 4 5 6 7 8 9
Session I 10 11 12 13 14 15 16
17 18 19 20 21 22 23
24 25 26 27 28 29 30
31 1 2 3 4 5 6
August Begin 1st 9 weeks 7 8 9 10 11 12 13
14 15 16 17 18 19 20
21 22 23 24 25 26 27
28 29 30 31 1 2 3
September Labor Day 5 6 7 8 9 10
11 12 13 14 15 16 17
18 19 20 21 22 23 24
25 26 27 28 29 30 1
End of First Quarter 2 3 4 5 6 7 8
October Fall Break 9 10 11 12 13 14 15
Begin 2nd 9wk 16 17 18 19 20 21 22
23 24 25 26 27 28 29
30 31 1 2 3 4 5
November 6 7 8 9 Veteran's10 11 12
13 14 15 16 17 18 19
20 21 22 Thanksgiv23 Holiday 24 25 26
December 27 28 29 30 1 2 3
4 5 6 7 8 9 10
11 12 13 14 15 16 17
End of Semester- 18 19 20 21 End of Sem22 23 24
Winter Break 25 26 27 28 29 30 31
January 1 2 3 4 5 6 7
Wickenburg Virtual Academy School Calendar
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Winter Break 25 26 27 28 29 30 31
January 1 2 3 4 5 6 7
Begin 3rd 9 weeks 8 9 10 11 12 13 14
MLK
Day15 16 17 18 19 20 21
22 23 24 25 26 27 28
February 29 30 31 1 2 3 4
5 6 7 8 Gold Rush9 10 11
12 13 14 15 16 17 18
19 20 21 22 23 24 25
March 26 27 28 1 2 3 4
End of 3rd 9 Weeks 5 6 7 8 End of 9 wk 22 10 11
Spring Break 12 13 14 15 16 17 18
Begin 4th 9 weeks 19 20 21 22 23 24 25
26 27 28 29 30 31 1
April 2 3 4 5 6 7 8
9 10 11 12 13 14 15
16 17 18 19 20 21 22
23 24 25 26 27 28 29
May 30 1 2 3 4 5 6
7 8 9 10 11 12 13
14 15 16 17 18 19 20
End of Semester- 21 22 23 24 Graduation25 26 27
Summer 28 29 30 31 1 2 3
Session II 4 5 6 7 8 9 10
11 12 13 14 15 16 17
18 19 20 21 22 23 24
25 26 27 28 29 30
