ASPIRA Bilingual Cyber Charter School
4322 North 5th Street 2nd Floor
Philadelphia, Pa 19140
Phone: 267-338-1045 Fax: 267-338-1052
www.aspiracyber.org
Re-enrollment Checklist
Listed below is a checklist of items that MUST be returned to ASPIRA Bilingual Cyber Charter School. Please use this document to track your submissions to us and ensure that you complete all requirements for registration.
State of Pennsylvania Charter School Enrollment Notification Form
ABCCS Enrollment Form
Student Information
Parent/Guardian Information
Special Program Information
Home Facilitator Agreement Form (Clearances must be provided if non-parent home facilitator.)
Annual Household Income Form
Picture Release Form
PSSA Agreement Form
Emergency Care Information Form
School Health Information Form
Private Dental Report
Private Physician’s Report
Additional Required Information:
Current Proof of Residency—Please include a copy of any of the following items: deed, lease,
current utility bill, property tax bill, vehicle registration, driver’s license, DOT identification card. Driver's License must be current. Document must be in the name of the homeowner or payee, must reflect the current address and must be current (within the past 30 days). Items NOT acceptable: credit card statement, bank statement, envelope, checks, etc.
Immunization Records—Please send a copy, not the originals.
Medical/Dental Forms (Please refer to the Health and Immunization Requirements to see which medical
forms you need to complete). NOTE: You do NOT need to complete the appropriate physical or dental
exams before enrolling.
ASPIRA Bilingual Cyber Charter School
4322 North 5th Street 2nd Floor
Philadelphia, Pa 19140
Phone: 267-338-1045 Fax: 267-338-1052
www.aspiracyber.org
Charter School Student Re-enrollment Notification Form
For School Year / 2015-2016Warning: A child enrolled in another public school or a nonpublic or private school cannot, at the same time, enroll in a charter school.
Name of Charter School: / ASPIRA Bilingual Cyber Charter School
Address: / 4322 North 5th Street, 2nd Floor
Philadelphia, PA 19140
Charter School
Contact Person: / Sheila Ramos- Pagan
Telephone: / 267-338-1045 / Email Address: /
I. Student Information:
Last Name: / First Name: / MI:
Home Address:
City: / State: / Zip Code:
County: / Telephone:
Mailing Address (If Different From Home Address)
City: / State: / Zip Code:
Date Of Birth: / Age:
II. School District of Residence and Former School Information
School District of Residence:
Former School Information (Other Than Pre-School):
Public School / Charter School / Home School / Nonpublic School
Student Not Enrolled in School Preceding Enrollment in Charter School Because:
Entering Kindergarten / Re-Enrolling Dropout / Other
Name of Former School:
Address of Former School:
Previous Grade: / Withdrawal Date From Former School:
Was Your Child Receiving Special Education Services Based On An IEP? / Yes / No
If Yes, Do You Have The Child’s Special Education Records (IEP)? / Yes / No
ASPIRA Bilingual Cyber Charter School
4322 North 5th Street 2nd Floor
Philadelphia, Pa 19140
Phone: 267-338-1045 Fax: 267-338-1052
www.aspiracyber.org
III. Parent/Guardian Information:Child Lives With: / Both Parents / Both Parents Alternately / Mother Only / Father Only
Legal Guardian / Foster Parents / Other Adult
Special Custodial Court Instructions:
(If Yes, Please Provide a Copy of Court Order.) / Yes / No
Complete Parent/Guardian Name and Address Information As Applicable
Father’s Name
Address:
City: / State: / Zip Code:
Home Telephone: / Work Telephone:
Mother’s Name
Address:
City: / State: / Zip Code:
Home Telephone: / Work Telephone:
If The Student Is Not Living With Parents, Please Complete This Section.
Guardian’s Name / Or / Foster Parent’s Name / Or / Other Adult Name
Name:
Address:
City: / State: / Zip Code:
My signature on this form indicates my decision to have my child attend the charter school named on page 1 of this form and signifies my request that appropriate school records be forwarded from the school district to the charter school. My signature also certifies that my child is not, and will not be, enrolled in another public school, a nonpublic school or a private school at the same time he or she is enrolled in this charter school.
Signature of Parent/Guardian: / Date:
IV. To Be Completed By Charter School:
Verification of Date of Birth: / Birth Certificate / Other
Proof of Residency / Mortgage Statement / Lease / Utility Bill / Other
Official Enrollment Date: / Anticipated Date of Attendance:
Grade Student Is Entering:
Signature of Charter School Representative:
ASPIRA Bilingual Cyber Charter School
4322 North 5th Street 2nd Floor
Philadelphia, Pa 19140
Phone: 267-338-1045 Fax: 267-338-1052
www.aspiracyber.org
ASPIRA Bilingual Cyber Charter School Re-enrollment Form 2015-2016
Student’s Legal Name:______
last first middle
Preferred Name:______Gender: Male Female Age: (as of 9/1/15) _____
Student's DATE of BIRTH: ______Student's CITY of BIRTH:______
Student's STATE of BIRTH:______Student's COUNTRY of BIRTH:______
Grade enrolling in THIS YEAR (2015-2016): K 1 2 3 4 5 6 7 8 9 10 11 12
Grade Level LAST YEAR (2014-2015): K 1 2 3 4 5 6 7 8 9 10 11 12
What is the student’s ethnicity?
Hispanic or Latino (any race) Not Hispanic or Latino
What is the student’s race? Select one or more races to indicate the student’s racial identity.
White Black/African American Asian American Indian/Alaskan Native Native Hawaiian/Other Pacific Islander
For students entering grades 9-12 for the 2015-2016 school year: What year did student first enter 9th grade?
2014-2015 2013-2014 2012-2013 2011-2012 2010-2011 2009-2010 2008-2009
Has the student ever lived outside the state of Pennsylvania? YES NO
If “YES,” please provide the date that he/she most recently entered PA (yyyy-mm-dd): ______-____-____
OR, if that is not possible, please provide the most recent date he/she enrolled in a school in PA:
(yyyy-mm-dd): ______-____-____
Mailing Address:
Street: ______Apartment: ______
City: ______State: ______Zip Code: ______-______
Home Phone: ______
Shipping Address:
(Must be the physical address of parent or legal guardian for materials delivery. No post office (P.O.) boxes. We cannot ship instructional materials without a physical address.)
Check if SAME as Mailing Address
Street: ______Apartment: ______
City: ______State: ______Zip Code: ______
PLEASE NOTE: If you are planning to move, please be sure to notify ABCCS in writing, or call the school at 267-338-1045, immediately. Shipping occurs periodically throughout the school year for some courses.
Failure to notify ABCCS of an address change may result in delayed materials receipt.
ASPIRA Bilingual Cyber Charter School Re-enrollment Form 2015-2016
To help us better serve your student’s needs and transition, we would like to know about any special services your student
has received or is required to receive under state or federal law. This information will not be used to determine enrollment
eligibility, but will be used to ensure that your child is provided with proper services.
Has your student participated in any of the following special services?
Special Education Gifted & Talented ESL (English as a Second Language)
Title 1/Chapter 1 504 Plan
Does your student have an Individual Education Plan (IEP)? Yes No
If yes, do you have a copy of the IEP? Yes No
If yes, please enclose a copy. A copy must be received to assist in meeting your student’s needs.
Emancipated Minor InformationIs the student an emancipated minor? Yes No
A student is considered emancipated if he/she is under 21 years of age and one or more of the following:
· Established a home apart from the control and support of their parents/legal guardians
· Married and living with his/her spouse
· Deemed legally emancipated
Enrolling this year
Enrolled last year
Not enrolling now
Enrolling this year
Enrolled last year
Not enrolling now
The school program requires that you specify an adult to be the Home Facilitator who will have the primary responsibility for working with your student on a daily basis. This Home Facilitator may be a parent, legal guardian, or someone else of your choosing. If other than a parent or legal guardian, you will be asked to provide additional information before you enroll.
Please designate the Home Facilitator, list his or her relationship to the student, and provide requested information below.
Home Facilitator’s Name: ______
Last First Middle
Relationship to Student: ______
Home Phone: ______E-Mail Address: ______
What language(s) does the Home Facilitator speak? ______
What language(s) does the Home Facilitator read? ______
What language(s) does the Home Facilitator write? ______
ASPIRA Bilingual Cyber Charter School Re-enrollment Form 2015-2016
Student Lives With: Both parents Both parents alternately (joint custody) Mother Only Father Only
Legal Guardian Other (Please Explain):______
Mother’s Name:______
Mother’s Mailing Address: Same as student’s
Street: ______Apartment: ______
City: ______State: ______Zip Code: ______
Mother’s Maiden Name: ______
Federal Employee? Yes No Migrant Worker? Yes No
Name of Employer: ______
Occupation: ______
Home Phone: ______Cell Phone: ______Work Phone: ______
Is it okay to contact you at work in case of an emergency? YES NO
E-Mail Address: ______
Highest level of education completed (optional):
GED High school Some college
Associate’s degree Bachelor’s degree Master’s degree or above
Father’s Name:______
Father’s Mailing Address: Same as student’s
Street: ______Apartment: ______
City: ______State: ______Zip Code: ______
Federal Employee? Yes No Migrant Worker? Yes No
Name of Employer:______Occupation: ______
Home Phone: ______Cell Phone: ______Work Phone: ______
Is it okay to contact you at work in case of an emergency? YES NO
E-Mail Address: ______
Highest level of education completed (optional):
GED High school Some college
Associate’s degree Bachelor’s degree Master’s degree or above
Annual Household Income
Please indicate total number of all household members, whether they receive income or not:
Using your calculated household income and the total number of children and adults living in your home, check the box on the chart below that most closely describes your family’s annual income:
FamilySize / Annual salary range – Please check one.
one / £ $0 to $14,157 / £ $14,158 to $20,147 / £ $20,148and above
two / £ $0 to $19,123 / £ $19,124 to $27,214 / £ $27,215 and above
three / £ $0 to $24,089 / £ $24,090 to $34,281 / £ $34,282 and above
four / £ $0 to $29,055 / £ $29,056 to $41,348 / £ $41,349 and above
five / £ $0 to $34,021 / £ $34,022 to $48,415 / £ $48,416 and above
six / £ $0 to $38,987 / £ $38,988 to $55,482 / £ $55,483 and above
seven / £ $0 to $43,953 / £ $43,954 to $62,549 / £ $62,550 and above
eight / £ $0 to $48,919 / £ $48,920 to $69,616 / £ $69,617 and above
nine / £ $0 to $53,885 / £ $53,886 to $76,683 / £ $76,684 and above
ten / £ $0 to $58,851 / £ $58,852 to $83,750 / £ $83,751 and above
Certification and Signature
I certify that all of the above information is true and correct and that all income is reported. I understand that this information is being given for the receipt of federal funds and that school officials may verify the information on the form.
Parent/Guardian Signature:______Date:______
Home Facilitator Agreement Signature Form
Student Name: ______
Home Facilitator Name: ______
Parent/Guardian Name (if not Home Facilitator) ______
______
Contact Information if HF is NOT Parent/Legal Guardian:
Address: ______
City: ______State:______Zip Code:______
Phone #:______Email:______
My signature indicates that I have read and understand the Home Facilitator Agreement enclosed in my registration packet. I agree (please check each box):
to comply with basic steps
to assist with student learning
to comply with state testing requirements
to communicate with ABCCS teachers, administrators, and staff
Home Facilitator Signature: ______
Date: ______
Parent/Guardian Signature (if not Home Facilitator) ______
Date: ______
Attendance Policy
2015-2016 School Year
Signature Page
I have read the attached material pertaining to ASPIRA Bilingual Cyber Charter School’s Attendance Policy for the 2015-2016 school year.
My signature indicates that I have read and understand ABCCS Attendance Policy.
Student Name (Please Print):______
______
Student Signature date
______
Parent/Guardian Signature date
Picture Release Signature Form
At the orientation meeting, a photo ID of each student is taken.
Acceptable Use Policy requires a parent signature before any photos of students or their work can be published on the web.
Please Check One:
I hereby give permission to publish my child’s picture and/or work on the
Internet/Website of the school for only those reasons that ASPIRA Bilingual Cyber
Charter School deems appropriate (example: advertisement or acknowledgement
of student’s work).
I do not give my permission to have my child’s picture and/or work published or used
in any way for advertising or acknowledgement.
______
Printed Name of Student
______
Printed Name of Parent/Guardian
______
Signature of Parent/Guardian Date
PSSA Agreement Form
I hereby certify that I will accept the responsibility of taking
______
Student Name
to whatever location deemed necessary and appropriate by ASPIRA Bilingual Cyber Charter School for the purpose of the State mandated PSSA testing. I certify here also that said student(s) will arrive at that location before the official starting time on the assigned day.*
Signed and Certified:
______
Printed Name of Parent/Guardian
______
Signature of Parent/Guardian Date
*PSSA testing for the 2015-2016 School Year will be scheduled during the following periods: