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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 DeWitt.

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

DeWitt 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 DeWitt 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 - DEWITT HEALTH INFORMATION

HEALTH INFORMATION - A copy of the students official immunization record is required for enrollment.
I hereby authorize school officials to seek medical treatment from an appropriate emergency medical treatment facility, and if deemed necessary, to transport the student to such facility.
List any ON GOING diagnosed medical conditions (allergies, health conditions, etc.) or other information which you want teachers and office personnel to be aware of. This information will be available for all authorized staff. Note: Depending on the health concern, there may be additional forms to provide.
SPECIFIC STUDENT HEALTH CONCERNS
Note: By indicating a medical condition, you must complete the corresponding forms which can be found under FORMS at dewittschools.net.
HOME LANGUAGE SURVEY
Please answer the questions below accurately and completely. The information is necessary to provide the most appropriate placement and instruction for your child and will not be used for any other purposes.
  2. Is there a language other than English spoken in the home?
  3. Does your child speak a language other than English?
This procedure meets federal requirments for identifying and assessing language minority students in order to provide appropriate instructional support services and resources and for those students found to be limited English proficient.

SECTION EIGHT - DeWitt MVA Student Contract

Section 21f Online Learning Courses

(To be completed with student, parent, and counselor or principal)


Student Name:

Student Requirements: Due to the uniqueness of the online learning program, certain standards and behaviors are expected of students. Parents and students are expected to complete the online readiness rubric located at Dewitt Community School's website prior to requesting their child in the program. Additional parent information can be obtained at:
http://media.mivu.org/institute/pdf/parentguide.pdf.

Please read through the following agreements and initial in the space provided:

As a student enrolled in an Online Section 21f Course, I am aware that:

SECTION NINE - DeWitt MVA Student Contract

Consequences for Violations:

1st offense: I will be given a verbal warning. My parents will be notified.
2nd offense: I will be given a written warning. My parents will be notified.
3rd offense: A parent meeting will be scheduled to review program placement.

Severe Misconduct:

Regardless of whether the offense is a first time offense, I may be removed from the course and/or program with a grade of "Failing" and will fall within the jurisdiction of reassignment to on campus classes at my school.

Student Acknowledgment and Understanding:

I have read, understand, and acknowledge all the expectations and the policies as set forth in this document.
I agree to abide by the guidelines as stated.

01/22/2020
Date

Parent/Guardian Acknowledgment and Understanding:


01/22/2020
Date

SECTION TEN - DeWitt MVA Student Contract

Student Enrollment Checklist


Name

An application must be completed and signed by a parent/ legal guardian or by students 18+. The application should be completed on the virtual school website: https://backontrack.education/.


Please use this checklist to ensure you have the required documentation to enroll your student(s). All enrollment information needs to be provided to DeWitt Public Schools PRIOR to the start of school.

DeWitt 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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