Imagine Bella Academy of Excellence

19114 Bella Drive

Cleveland, Ohio 44119

(216) 481-1500 (Main)

(216) 481-4515 (Fax)

ENROLLMENT PACKET

(2017-2018)

Thank you for choosing Imagine Bella Academy of Excellence. Please complete this application as soon as possible to ensure a seat for your child.

Sincerely,

Arun Dutt

Principal

Student: ______
Current Grade: _____ School District______
Application Date: ______Start Date ______

Information Required:

It is very important that your application be completed in full. To enroll your child in the Bella Academy of Excellence we need to have the following information:

Social Security Card / Physicians Record (signed)
Birth Certificate / Medication Request (signed) (If Applicable)
Proof of Residence / CPS4 – Withdrawal to Community School (signed)
Immunizations
Last Report Card (not applicable for students enrolling in Kindergarten for the first time)
Enrollment Application
School Policies
Student Medical History/Immunizations
Pick up List
Permanent Record Request
School Policy Consent

Reminder and Comments:

______

*****Email and Scan to EMIS Coordinator*****

MISSION:

Preparing students for academic excellence and lifetime achievement.

VISION:

Creating an innovative and academically excellent learning environment which is centered on students, directed by teachers, and supported by home and community

UNIFORM POLICY

The Bella Academy of Excellence dress code attire consists of:

  • Navy Blue, Black or Khaki pants, skirts, jumpers or shorts (not more than one inch above the knee).
  • Any solid colored, button, or collared shirts. Shirts should be polo or oxford style.

No logos, stripes, writing or pictures.

  • Solid Navy Blue, white, or black sweater, sweater vests and cardigans.

No Sweatshirts or Hoodies. No argyle sweater vests.

  • Black or brown dress shoes or majority black or brown tennis shoes with black or brown laces are expected daily.

No colors, glitter, designs, flashing lights, etc.

  • Boots ARE NOT to be worn during the school day. In case of snow boots, please provide your child with appropriate school shoes.
  • Navy blue, Khaki, black, or white socks.
  • No distracting hair accessories.
  • Jewelry is limited to small earrings and necklaces for both girls and boys.

VISITOR POLICY:

Visitors are welcome at all times. For the safety of our students and staff, visitors must first report to the office and receive a visitor’s badge by presenting their valid Driver’s License. When visiting the school with the intent to speak with a teacher or checking in on your child, please make an appointment so that the teacher can set aside proper time to focus on your conversation. People who are regularly in the building for volunteer purposes must be fingerprinted as mandated by law.

STUDENT PICK-UP:

You must sign students out when picking them up prior to dismissal. You must check in at the office upon arrival and be at least 18 years old and may be asked for identification. We do not release students between 3:30 p.m. and 4:00 p.m., unless written or verbal notice has been submitted. If this pick up time becomes habitual, Administration has the right to request documentation for early dismissal. We will send for the student to be dismissed, parents/guardians are not permitted to get students from the classroom.

STUDENT LATE ARRIVAL:

Students arriving to school tardy, after 8:30 a.m., must receive a tardy slip from the front office. Parents/Guardians will not be permitted to walk the student to class after 8:30 a.m., due to instruction. Late students will not receive breakfast (service ends at 8:20 a.m.)

NONDISCRIMINATION POLICY:

Our School admits students of any race, color, national and ethnic origin and does not discriminate on the basis of race, color, national origin, disability, age or sex in administration of its educational policies, admissions policies, scholarship and loan programs and athletic and other school administered programs.

Bella Academy of Excellence established under Chapter 3314 of the Revised Code. The school is a public school and students enrolled in and attending the school are required to take achievement tests and other examinations prescribed by law. In addition, there may be other requirements for students at the school that are prescribed by law. Students who have been excused from the compulsory attendance law for the purpose of home education as defined by the Administrative Code shall no longer be excused for that purpose upon their enrollment in a community school. For more information about this matter, contact a school administrator of the Ohio Department of Education.

STUDENT INFORMATION

STUDENT DATAGrade to be enrolled: ______

Last Name: ______First Name: ______Middle: ______
Birth Date: ______Birth City: ______Social Security No.: ______-______-______
Gender (Circle): M F Proof of Age (Circle): Birth Certificate Other (Please Name): ______
Ethnicity (Circle): American Indian/Alaskan Native Asian/Pacific Islander Black (non-Hispanic)
Hispanic Multiracial Caucasian/White
Other______
Student Address: ______
City: ______State: OH Zip: ______Home Phone: ( )______
Dwelling Type (Circle): House Apartment Other (Please Name): ______

ADDRESS:

Proof of Address (Circle or Specify in “Other”): Landlord Statement Lease Utility Bill Other:______
Is the Student address the same as the address above? Yes No If no, please fill in student’s mailing address below:
Student Mailing Address: ______

SCHOOL DISTRICT:

Has your child ever attended a Public School? Yes No
What is your Resident School District? ______(The school district where you live.)

INDIVIDUAL EDUCATION PLAN:

Does your child have an Individual Education Plan (IEP)? (Please circle.) Yes No
Has your child ever had an Individual Education Plan (IEP)? (Please circle.) Yes No
__

KINDERGARTEN:

Did your child attend Kindergarten? (Please circle.) Full Day Half Day Not At All
Did your child attend Preschool? (Please circle.) Full Day Half Day Not At All
_

As a Community School, parent involvement is a very important. By enrolling your child, you are agreeing to play a vital role in your child’s education. You are required to drop off and pick up your child on time, attend conferences, return forms in a timely manner and call in student absences. More importantly, we will count on you to volunteer and participate regularly in the best interest of the school.

I support the educational philosophy of Imagine Schools and hereby submit my application to enroll my child.

______

Parent/Guardian Signature Parent/Guardian Printed Name Date
ADDITIONAL ASSISTANCE FORM

Student Name ______Student Date of Birth ______

(Please Print)

Name of School Your Child Attended Last Year: ______

1. Has your child ever repeated a grade? YesNo

2. If yes, then what grade was repeated? ______

3. Was your child’s attendance good at their previous school(s)? Yes No

4. Did your child experience any difficulties at their previous school?YesNo

If yes, please explain: ______

______

5. Did you child receive any extra help at his/her previous school? YesNo

(For example: Title One, counseling, before or after school tutoring, etc.)

If yes, please explain: ______

______

6. Is your child performing at grade level in reading and math? YesNo

Please explain ______

7. Was your child tested due to academic or behavior issues at his/her previous school?

YesNo

If yes, please explain: ______

______

8. Has your child been identified as having a disability either by an outside source or his/her previous school? Yes No

If yes, please explain: ______

______

9. Does your child currently receive special education services for speech or another disability? Yes No

If yes, please explain: ______

______

10. If you answered “Yes” to #4 then, do you have a current, signed copy of your child’s Evaluation Team Report (ETR) and Individualized Education Plan (IEP)? Yes No

If you answered yes then you will need to bring the ETR and/or IEP with you when you return this form if your child did not attend Bella Academy of Excellence last year.

Home Language Survey

1. What language did your child speak when they first learned to talk?______

2. What language does your child use most frequently at home?______

3. What language do you use most frequently to your child?______

4. What language do the adults at home most often speak?______

5. How long has your child attended school in the United States?______

STUDENT MEDICAL RECORDS

STUDENT DATA:

Last Name: ______First Name: ______MI: _____

Gender (circle): M F Birth Date: ______

HEALTH HISTORY:

CIRCLE ANY CONDITIONS THAT HAVE BEEN EXPERIENCED BY YOUR CHILD:

Chicken Pox / Diabetes / Eye Problems/Vision / Frequent Ear Infections
Tubes in Child’s Ears / Frequent Headaches / Frequent Nosebleeds / Frequent Sore Throat Infections
High Fevers / Poor Hearing / Seizures or Epilepsy / Sickle Cell Disease

Is your child sick a lot? Yes No

If Yes, please explain:______

______

MAJOR ILLNESSES, INJURIES OR SURGERIES:

Has your child had any major illnesses, injuries or surgeries? Yes No

If Yes, please list:

1. ______/ 2. ______
3. ______/ 4. ______

MEDICATIONS:

Does your child take any medications frequently or daily? Yes No

If Yes, what medications are taken daily? ______

If Yes, what medications are taken frequently, but not daily? ______

This child is usually (circle one):very active normally active rather inactive

ALLERGIES:

Has your child been diagnosed with asthma or allergies by a doctor? Yes No

If Yes, please explain: ______

Is your child on any medicine (prescription or over-the-counter) for allergies? Yes No

If Yes, please explain: ______

Please list and describe allergies or reactions to:

Medicines/drugs: ______

Foods/Plants/Others: ______

Bee/Wasp Stings: ______

STUDENT EMERGENCY CONTACT/PICK UP LIST

CUSTODY INFORMATION:STUDENT NAME: ______
Who has custody of this student NOW? (Circle Only One:)
Both Parents Mother Only Father Only Guardian Other
I certify that I have legal custody of ______.
Signature ______Date______.
Custodial parents may always pick up their children. However, in an event that others may need to pick up your children, please list people that are allowed to pick up your children. These people will be required to show their driver’s license for identification so please include information below that will match this information. If one of these people will be picking up your child, please call the school office in advance to notify us of the change.

PARENT/GUARDIAN INFORMATION (PLEASE PRINT):

PARENT/GUARDIAN 1 / PARENT/GUARDIAN 2
Last Name: / Last Name:
First Name: / First Name:
Address: / Address:
City : / City:
State: / Zip: / State: / Zip:
Relationship to Student: / Relationship to Student:
Employment: / Employment:
Work Phone: / Work Phone:
Home Phone: / Home Phone:
Unlisted? Yes No / Unlisted? Yes No
Cell Phone: / Cell Phone:
Fax Number: / Fax Number:
Email: / Email:
EMERGENCY CONTACT INFORMATION and PICK UP CONTACT(PLEASE PRINT):
FIRST PERSON TO CONTACT / SECOND PERSON TO CONTACT
Last Name: / Last Name:
First Name: / First Name:
Address: / Address:
City: ______State: ___ Zip: ______/ City: ______State: ____ Zip: ______
Relationship to Student: ______/ Relationship to Student: ______
Employment: ______/ Employment: ______
Work Phone: ______Ext: ______/ Work Phone: ______Ext: ______
Home Phone: ______Unlisted? Yes No / Home Phone: ______Unlisted? Yes No
Cell Phone:______/ Cell Phone: ______
E-Mail Address: ______/ E-Mail Address: ______

**If additional contacts need to be added, please ask for another form**

REQUEST FOR PERMANENT RECORDS

______has enrolled in Imagine Bella Academy of Excellence and the

student’s first day was ______.

Please send the following information to:

Imagine Bella Academy of Excellence

Enrollment Office

19114 Bella Drive

Cleveland, Ohio 44119

PLEASE SEND ANY AND ALL INFORMATION BELOW:

__ Social Security Card / __ Grade Card (or information about pupil placement)
__ Birth Certificate / __ Attendance
__ Proof of Residency / __ Intervention Assistance Team Documents
__ Immunization Record / __ Special Education IEP/MFE
__ All Medical Records / __ Expulsion/Suspension Documents
__ Custody/Court Documents / __ Retention Records(from any school year)
__ Copy of Student’s Data Form
__ Cumulative Records / __ Third Grade Reading Guarantee Test Scores/Status/Fall Reading Diagnostics (K-3)
TO BE COMPLETED BY PARENT OR GUARDIAN:
Name of school your child last attended: ______
School Address:______
City: ______State: OH Zip: ______
Phone: ______Fax: ______
Last Grade Attended: ______Date of Birth______

Other Schools Attended Previously: ______

______

______

AUTHORIZATION:
PRINT NAME of Parent/Guardian: ______
SIGNATURE of Parent/Guardian: ______
Date: ______

SCHOOL POLICY AUTHORIZATIONS

AUTHORIZATION – DRESS CODE, VISITOR’S & LATE ARRIVAL POLICY
My signature below indicates that I have read the DRESS CODE POLICY, the VISITOR’S POLICY and the LATE ARRIVAL POLICY. I understand the consequences that are associated with not complying to the said policies, and I agree to the terms stated within said policies.
PRINT NAME of Parent/Guardian:
______
SIGNATURE of Parent/Guardian: Date:
______

MEDIA INTERVIEWS & PHOTO RELEASE

From time to time outside agencies (local radio or television stations, newspaper or community/state agencies) highlight exemplary programs in our area. This often involves video taping or taking pictures of students in the classroom setting and/or asking students for their opinions or questions about their educational experiences.

While reading that the public has a right and a responsibility for access to information about the activities in our schools; Bella Academy of Excellence is very selective in granting such access to the classroom. Please indicate your feeling regarding your child’s involvement in media events by signing one of the following statements:

AUTHORIZATION – MEDIA INTERVIEWS & PHOTO RELEASE
I, the parent/guardian of ______DO give my permission for my child to participate in approved media interviews/video tapes/photographs and release the school and said agency from all claims based upon this activity.
SIGNATURE: ______Date: ______
______
I, the parent/guardian of ______DO NOT give my permission for my child to participate in approved media interviews/video tapes/photographs.
SIGNATURE: ______Date: ______

STUDENT MEDICAL RECORDS

PHYSICIAN RECORD

STUDENT NAME: ______

SCREENINGS (can be completed by nurse or physician):

Height: _____ ( %) / Weight: _____ ( %) / Blood Pressure: _____ ( %)
VISION / HEARING / SPEECH & LANGUAGE
Distance Acuity R_____ L_____ / Audiometric Thresholds: / Speech Assessment:
Muscle Balance: Pass Fail Not Done / Right Ear: Pass Fail Not Done / Done Not Done
Farsightedness: Pass Fail Not Done / Left Ear: Pass Fail Not Done / Child has possible problem with:
Color: Pass Fail Not Done / Other Tests (specify): ______/ Articulation Yes No
Rhythm Yes No
Child wears glasses? Yes No / Child wears hearing aid? Yes No / Voice Yes No
Language Yes No
Tested with glasses? Yes No / Tested with hearing aid? Yes No
Speech evaluation recommended?
Referral made? Yes No / Referral made? Yes No / Yes No

IMMUNIZATIONS (can be completed by nurse or physician):

DPT 1st ______2nd ______3rd ______4th ______
Polio 1st ______2nd ______3rd ______4th ______
Hep B 1st ______2nd ______3rd ______
Mumps 1st ______2nd ______Tuberculin Test Date: ______
German Measles (Rubella) 1st ______2nd ______Results: Negative___ Positive___
Measles (Rubeola) 1st ______2nd ______
Varicella 1st ______2nd______

EXAMINATIONS (can be completed by nurse or physician):

Head ______/ Mouth______/ Genitalia______/ Lungs______
Neck______/ Teeth______/ General Condition______/ Hernia______
Nose______/ Abdomen______/ Orthopedic______/ Urinalysis______
Throat______/ Heart______/ Nervous System______

PHYSICIAN REMARKS & RECOMMENDATIONS:

Physician Remarks & Recommendations: / This child is authorized to participate fully in:
- classroom & academic activities Yes No
- physical education classes Yes No
- competitive athletics Yes No
- contact & collision sports Yes No
Physician Signature: ______
Date: ______/ (Specify Limitations in REMARKS)

STUDENT MEDICAL RECORDS

MEDICATION REQUEST

The following student is under my care and should receive the medication indicated below. It is not possible to arrange for medication to be taken at home under the supervision of a parent, and therefore, must be taken during school hours.

ONE MEDICATION PER CARD

Last Name: ______First Name: ______MI: ___ Birth Date: ______
Student Address: ______
City: ______State: OH Zip: _____ Home Phone: ______
Name of prescribed medication:______Dosage: ______
Number of times/intervals medication is to be administered: ______
Dates administration to begin and end: ______
Adverse or severe reaction that should be reported to physician: ______
Special instructions for administration of medication: ______
The medication can be safely administered by non-medical personnel: Yes No
______
Physician’s Name Phone Number
______
Physician’s Signature Date

Printed 3/16/17