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800-297-2119

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Student Information/Demographics - MVA

(From Birth Certificate)
(Last)
(First)
(Middle)
(Optional)






Military connected student

SECTION TWO - PARENT/GUARDIAN INFORMATION

PRIMARY HEADS OF HOUSEHOLD (With whom does the student reside?)












Primary Household Data
Primary Head of Household 1
Primary Head of Household 2
SECONDARY HEADS OF HOUSEHOLD






 




If you answered "No" to either of these questions, please attach legal documentation specific to the child
Secondary Household Data
Secondary Head of Household 1
Secondary Head of Household 2








SECTION THREE - SPECIAL NEEDS / ETHNICITY / HEALTH INFO








WIDA-A Access assessment for ELL (English Language Learners) students must be taken as mandated by the Michigan Department of Education as part of the state testing and assessments.

*Students that are English Language Learners must agree to participate in this yearly assessment
HEALTH INFORMATION
Medical information is confidential and will be shared with personnel on a need to know basis.



SPECIAL NEEDS INFORMATION

My child is currently following curriculum leading to a:

Has the student been previously suspended?
Has the student been previously expelled?  


ETHNICITY (Part A) and RACE (Part B)
Race and Ethnicity Both Part A and Part B of the question must be answered.
If either part is not answered, the US Department of Education requires the district to supply an answer on your behalf.
Part A: Ethnicity
(choose only one)
Is this student Hispanic/Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin, regardsless of race.)

 
Part A refers to ethnicity, not race. No matter which box you selected above, please continue to answer
Part B (below) by marking one or more boxes to indicate what you consider your students race to be.
Part B: Race
(Choose one or more)
When choosing more than one, enter % for each ethnicity

SECTION FOUR - PREVIOUS SCHOOL INFORMATION

SECTION FIVE - ADDITIONAL EMERGENCY CONTACT INFORMATION (NOT PARENTS)

Name
Relationship Type
Work Phone
Cell Phone
Home Phone
Contact 1
Contact 2
Contact 3
Doctor Contact
Doctor
If a medical emergency exists, the school will take appropriate action on behalf of the child. The family will assume all medical costs.
OTHER SIBLINGS LIVING AT HOME
Name
Gender
Birth Date
School
Grade
Sibling 1
Sibling 2
Sibling 3

SECTION SIX - DISCLAIMERS

,

Michigan State Required Testing

It is mandatory that students in our program participate in state and federal testing during required dates. Please note that families are also responsible for travel costs associated with commuting to our physical building location(s) for orientation(s), state and federal testing purposes, and any other required activity. Families should consider travel limitations before enrolling at our school.




If yes, who is not allowed to have contact with the student?
***NOTE*** The school must have a copy of the order to deny release/contact to a parent.

Please review: Understanding Concussions

As the Parent/Guardian of this student, I have received the UNDERSTANDING CONCUSSION information. I acknowledge in accordance with Public Acts 342 and 343 of 2012 that I have received and reviewed the Concussion Fact Sheet for Parents and/or the Concussion Fact Sheet for Students provided by Buchanan.

I authorize the school district to release my child's immunization record to the Michigan Department of Health and Human Services and Local Health Department. I understand this information will be used to improve the quality and timeliness of immunization services and to help schools comply with Michigan Law. This includes any immunization information and limited personally identifiable information from the school.

Please review: Network And Internet Access Agreement for Students







Please Read: Presenting false information, false records or falsifying records is an offense punishable by federal and state law. By signing below, you attest that all information provided on this form is true and accurate.
Parent/Legal Guardian Electronic Signature (or Student if 18 or over)
Date
Press/Video Release

Buchanan Schools has my permission to use photographs and/or videos of my child to show school activities to the public. I understand that the personally identifiable information may be used at the discretion of the media, involving no financial compensation to Buchanan Schools, the student, or the family of the student. The final edited pictures and sounds may be shown without restriction, including radio and television broadcast, cablecast, printed publication, website and any other social media. I understand that I have the right to deny consent to the release of the photographs and/or information specified above, by refusing to sign this. If you consent, please sign here:


Date
If permission is denied, please write “DENIED” on the signature line

Please Read: Presenting false information, false records or falsifying records is an offense punishable by federal and state law. By signing below, you attest that all information provided on this form is true and accurate.

SECTION SEVEN - HOUSEHOLD INFORMATION SURVEY

HOUSEHOLD INFORMATION SURVEY

School District Name: Buchanan MVA

Address 1: 18901 15 Mile Rd

Address 2:

City, State, Zip: Clinton Township, MI, 48035

Phone: 800-297-2119

Email:

SCHOOL USE ONLY

Approved for:

 

To determine eligibility for various additional state and federal program benefits that your child(ren) may qualify for, please complete, sign and return this application to Buchanan Schools.

These sections must be completed by the head of household or designee.

PART A. SIZE OF FAMILY - Enter the number of individuals living in your household, including all adults and children →

PART B. CURRENT BENEFITS - Complete below if applicable

If any member of your household receives Food Assistant Program (FAP), Family Independence Program (FIP), or FDPIR, provide the name and case number of the person who receives the benefits. Bridge Card Numbers and Medicaid Numbers are NOT ACCEPTABLE case numbers.

PART C. STUDENT INFORMATION - Complete for each student Pre-K through 12th Grade*

*For the IDENTIFY field please use the following: H if Homeless, M if Migrant, R if Runaway, F if Foster, N/A if Not Applicable

Student 1
/ /
Student 2
Student 3
Student 4
Student 5
Student 6
Student 7
Student 8

If you need additional lines, attach a second sheet to this survey or attach a copy of this survey clearly marked as Page 2.

PART D. TOTAL MONTHLY HOUSEHOLD INCOME - Report income for all members of household excluding foster children. If you have reported a case number above, you do not need to fill in this section. Simply sign and date form.

Type of income
Income
Check if no income

1. Gross Monthly Earnings: Wages, Salary, Comissions

2. Monthly Welfare Payments, Child Support, Alimony

3. Monthly Payments from Pensions, Retirement, Social Security

4. Monthly Dividends or Interest on Savings

5. Monthly Worker's Compensation, Unemployment, Strike Benefits

6. Other Monthly Income (SSI, VA, Disability, Farm, Other)

Total Monthly Household Income (Add lines 1-6)

PART E. SIGNATURE - If Income Section is completed, the adult signing the form must also list the last four (4) digits of his or her Social Security Number or check the "I do not have a Social Security Number" box below.

I certify (promise) that all information on this application is true and that all income is reported. I understand that the sponsor will get federal/state funds based on the information I give. I understand that sponsor officials may verify (check) the information.

Date: 01/22/2020



By providing your email address you may be contacted via email by the district

Buchanan Student Enrollment Form ONLINE LEARNER READINESS RUBRIC

Name:
Date:

1. My access to technology is best described as:



2. My experience with discussion boards/online bulletin boards (Moodle, Blackboard, etc.) is:



3. My technology skills are best described as:



4. When working with technology:



5. When starting a new school lesson/unit:



6. When I need help in class:



7. When it comes to completing school work:



8. When it comes to reading and writing:



9. I think an online class:



10.

FILE UPLOADS

Required Documents:

Birth Certificate

Picture I.D.

Proof of Residency (Utility Bill, Lease Agreement)

Shot/Immunization Record

All High School Transcripts

Upload Your Documents

To help expedite your application process, we give you the option to upload digital versions of any or all of these documents onto our secure, encrypted servers.

Once your files are received, they will be removed from the site and stored in our office.

Depending on the district, you may be asked for other documents.

To upload your files, check the boxes above to indicate which documents you are including then select the files on your computer in the popup window after clicking 'Upload Your Documents'

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