dear parent or guardian, - ucpcfl.org · dear parent or guardian, thank you for considering ucp of...

Dear Parent or Guardian,

Thank you for considering UCP of Central Florida’s Education Program. We believe every child deserves excellent academics to help them learn, grow and excel. That’s why each of our classrooms is led by highly-qualified and experienced teachers who welcome children and families into a community of learning. Our research-based academics lay the foundation for each student’s future success.

The mission of UCP Charter Schools is to create a fully inclusive learning community where all students, parents, and professionals appreciate and value diversity in all forms. Students are educated to become conscientious responsible citizens, whereby they assume the role of life-long learners as they reflect upon and contribute to the cultural and civic life of their community. All students are supported to achieve high standards in both their academic and personal development through a research-based educational program utilizing an inquiry/project-based program integrating arts and technology.

Please find enclosed UCP’s application for enrollment. The next step in the enrollment process is the completion of this packet and submission of other documents. It is important that you complete each form in the packet as much as possible. Additionally, please use the Checklist to gather the other needed documents. Please return this packet and the materials to the front desk at the campus in which you are applying.

Once all materials are received, your child will be evaluated for placement and you will be notified of the next steps. If you have any questions on the process or forms/documents, please contact the Family Service Case Manager at your child’s campus at 407-852-3300:

UCP Seminole – x2000 UCP TLA – x8323 UCP West Orange – x5000

UCP Bailes/East Orange – x1000 UCP Downtown/ BETA – x7313 UCP Osceola – x6000 UCP Pine Hills – x4000

Thank you again for considering UCP of Central Florida!

Dr. Ilene Wilkins, President/CEO

Thank you for selecting UCP of Central Florida as your child’s school provider. Please fill out each page of the packet as thoroughly as possible. In addition, please look over the enclosed list of items and bring the applicable documents with

you to your child’s school before the first day of class.

Verification of legal name and age with child’s birth certificate.

Proof of immunizations on Florida State Form 680, which can be obtained from your physician or at the HealthDepartment in the following counties (please call the Health Departments for details and requirements):

• Orange County Health Department (407-836-2502) at 832 W. Central Blvd., Orlando• Seminole County Health Department in Sanford (407-665-3281) or Casselberry (407-665-3409)

• Osceola County Health Department in Boggy Creek (407-343-2066), Poinciana (407-943-8600) orSt.Cloud (407-943-8699)

**Proof of physical examination on Florida Department of Health Form 3040, performed by a U.S. doctor within 1 yearof school enrollment (1st day of school). If documentation cannot be provided, a physical examination must be scheduledwithin 30 days of the first day of school.Note: Seminole County Public Schools’ policy does not grant a 30 day extension to obtain required immunizations or aphysical.

Verification of Academic History

1. Last report card -- if applicable.

2. Withdrawal form from previous school (private, public, in-state, or out of state) if applicable. Forstudents with a disability please bring an Individual Education Plan (IEP) and most recent psychoeducation evaluation.

3. School transcript

Verification of Special Education1. Children age 0-3 with disability - Part C / Early Steps / Individual Family Support Plan (IFSP)

2. Children over 3 years of age with a disability - School District Individual Education Plan (IEP) andmost recent psycho education evaluation.

Verification of your residential address in the appropriate county with one of the following*:1. Current Homestead Exemption Card or Purchase Contract or Warranty Deed2. Lease / Rental Agreement3. Verification of address: Documents required-information available on County School District website.

(Seminole County has different requirements)

Guardianships - If you are not the legal guardian or residential custodial parent of a student, state law requiresthat one of the following documents be provided for enrollment

1. Court Custody Documentation – this includes divorce decrees, parenting agreements (if applicable)2. Department of Children and Families Placement Letter3. School Educational Guardianship notarized statement from public school system

Copy of VPK documentation/VPK Voucher (if applicable)

Medical Records & Evaluations (for therapy services only)1. Insurance Card, Policy Card or Medicaid Card2. Physicians Script for Evaluation (with diagnosis)3. Copies of all previous therapy evaluations, progress notes and discharge reports4. Copies of all relevant previous medical records within the last two years

*Temporary Documentation Exemption: Students who lack a fixed, regular and adequate nighttime residence, have a right to immediate enrollment underthe McKinney-Vento Homeless Assistance Act 42 U.S.C. 11435. A completed Student Residency Questionnaire is needed to determine eligibility.

**Seminole County Public School’s policy does not grant a 30-day extension to obtain required immunizations or a physical. Immunization and physicals may be obtained through your physician.

Bailes/East Orlando Campus (Near UCF)

Downtown/BETA Campus

Osceola/Kissimmee Campus

Pine Hills Campus

**TLA Campus (South Orange Ave.) Seminole/Lake Mary Campus

West Orange/Winter Garden Campus

Visit:

www.ucpcfl.org for more information.

** Middle and High School & College/Career Transition Program ** Campus serves grade 6 through age 21.

Student Number_________________________ [OFFICE USE ONLY]

*Child’s Legal Name:

First MI Last Generation (i.e.: Jr., II)

Date of Birth Birth Place (City, State, Country)

Social Security Number (Optional) Grade at Entry

*Residential Address:

Street Address

City State Zip County

*Mailing Address: Check if same as residential

Street Address

City State Zip County

*Ethnicity: Hispanic/Latino Non Hispanic/Non Latino

*Race (Check all applicable): White Asian Black or African American

American Indian/Alaska Native Native Hawaiian or other Pacific Islanders

*OK to Release Directory Information? Yes No

(Answering “yes” to one or more of the home language questions below, will require your child to be screened for English Language proficiency)

*Home Language: Is a language other than English spoken at home?

Yes No If yes, what language?

*Dominant Language: Does the student most frequently speak a language other than English?


*Native Language: Did the student have a first language other than English?


Do you need communication sent home in a language other than English?

Yes No If yes, check all that apply: Spanish French Portuguese

Haitian Creole Vietnamese Other________

Born Outside the United States?

Yes No *If yes, Date entered in U.S.?

*Date your student entered first U.S. school:

Child resides at residential address with:

/ / (Mo/Day/Year)

Both parents Mother only Father only Parent and step parent

Legal guardian Foster Parent Other:

Form

* denotes required field - please fill out.

*Verification of Residence required for Parent or Guardian without a lease or living with another person

*Gender: M F

Residential Information (Please check all that apply): Parent/Guardian is in Federal Military Services or is a civilian employee

Parent/Guardian has lived in Florida for the past year or longerParent/Guardian has purchased and occupies as his/her domicile a home in Florida

Y

Parent/Guardian is a migratory agriculture worker

Parent/Guardian has a *Verification of Residence:

Parent/Guardian has a valid lease agreement: Y N N

Expiration Date:___________________

Other School Age Children Living at Home:

Child’s Name (First and Last) Relation to Students School Grade

1.

2.

3.

Has your child been identified as an exceptional education student? N Y

Does your child have a current IEP, 504 or IFSP? N

Has your child ever received a McKay Scholarship?

Y Please Bring a Copy

N

IEP 504 IFSP

Y

*School History (Begin with the most recent - For Kindergarten registration, please list Pre-K)

Please check here if your child has ever attended any Florida School.

When______________ City______________ County______________ Public Private

1. Current School:

School Name Address Phone Number

Type of School Years Attended Last Grade Completed

Public Home Education Private

2. Past:




3. Past:




Program Participation Prior to Kindergarten: (Check all that apply)

(V) Voluntary Pre-Kindergarten at a Public School School Name:

(P) Pre-Kindergarten Program (VPK) at Private School School Name:

(D) Pre-Kindergarten Program for children with Disabilities School Name:

(H) Head Start School Name:

(F) School District Pre-K School Name:

(M) Migrant Pre-K School Name:

(C) Title 1 Pre-K School Name:

(T) Teenage Parent Program Pre-K School Name:

(N) None

* denotes required field - please fill out.

Has student been arrested, resulting in a charge? N Y

(If yes to previous) Date: Name of school: County/State:

Has student been expelled from a previous school? N Y

Name of school: (If YES) Date:

First MI Last

Street Address City State Zip

Home Phone Cell Phone E-mail Address

Date of Birth Relationship to student Legal Documentation (Ex: custody, restraining order, etc.) If there is no Legal Alert: Enter “N/A” *Please provide supporting documentation

837.06 False official statements. - Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his or her official duty shall be guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 775.083

Falsification of information will forfeit student’s athletic and extracurricular activity for one (1) calendar year from the date of discovery of the violation.

Best time to call: Evening

Marital Status: Widowed

Employment Status:

Divorced

Part Time

Separated

Retired Self-Employed

Parent Family Income:

Afternoon

Married

Full Time

Not Working

$10,000-$14,999 $15,000-$19,999 $20,000-$29,999

Morning

Single

Active Military

In School/Training

Below $10,000

$30,000-$49,999 $50,000-$74,999$ 75,000-$99,999 $100,000 and above

Has student ever had Juvenile Justice action taken against him/her? N Y

NIs student on Community Control? Y

Is the student a parent? N Y

NCurrently under Physician’s Care? Y

Physician Information:

Primary Doctor’s Name Address Phone

Primary Dentist’s Name Address Phone

Preferred Hospital: ___________________________________________________________________

Funding Information (Check all that apply)

Kid Care 4C Early Steps Early Head Start Commercial InsuranceMedicaid HMO

Private Pay

Medicaid

Other:

Insurance Information If Commercial Insurance, please complete the following.

Policy Holder’s Name Name of Insurance

Group # Policy #

*Parent/Guardian #1 Information:

Custody:

Y N

OK to pick up:

Y N

Parent Guardian Guardian Ad Litem Surrogate Parent Other/Relative

Address:

Parent/Guardian is a:

Primary Parent’s Employer:

Phone: Occupation:

Parent/Guardian #2 Information:

Custody: (Circle One)

Y N

OK to pick up: (Circle One)

Y N

First MI Last

Street Address City State Zip

Home Phone Cell Phone E-mail Address

Date of Birth Relationship to student Legal Documentation (Ex: custody, restraining order, etc.)

837.06 False official statements. - Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his or her official duty shall be guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 775.083

Falsification of information will forfeit student’s athletic and extracurricular activity for one (1) calendar year from the date of discovery of the violation.

Military Family Student Survey:

No Yes

No Yes

No Yes

Parent is an active duty member of the uniformed services, including members of the National Guard and Reserve on active-duty orders.

Parent is a member or veteran of the uniformed services who is severely injured and medically discharged or retired for a period of 1 year after medical discharge or retirement.

Parent died as an active duty member of the uniformed service or within one year of injury.

Evening

Divorced

Part Time

Separated

Retired

Widowed

Self-Employed

Best time to call:

Marital Status:

Employment Status:

Parent Family Income:

Afternoon

Married

Full Time

Not Working

$10,000-$14,999 $15,000-$19,999 $20,000-$29,999

Morning

Single

Active Military

In School/Training

Below $10,000

$30,000-$49,999 $50,000-$74,999$ 75,000-$99,999 $100,000 and above

Parent Guardian Guardian Ad Litem Surrogate Parent Other/Relative

Address:

Parent/Guardian is a:

Primary Parent’s Employer:

Phone: Occupation:

How did you hear about UCP of Central Florida? Physician

Name:

UCP Staff Member

Name:

Address: Former Student

Name:Hospital:Early StepsSocial Media/Google

MailingEarly Head StartSchool: Orange County Public SchoolsSchool: Seminole County Public SchoolsSchool: Osceola Public School System

School: Other:4CParent

Name:

WebsiteInternet SearchFacebook

TwitterYouTubeAdvertisement: MagazineAdvertisement: PostcardAdvertisement: Flyer

Advertisement: NewspaperOther :

As the custodial (custody at least 50% of the time) / enrolling parent I verify that the information provided above is true and correct, and understand that The School District of Orange, Osceola and Seminole Counties will rely upon this information as true and correct. Parent acknowledges that there are legal penalties, including possible criminal penalties, for intentionally providing false information to the School District. I further understand that providing false or misleading information may result in my child being excluded from school.

Parent/Guardian Signature #1 :

Date: ______________ Relationship to student: _________________

Parent/Guardian Signature #2:

Date: ______________ Relationship to student: _________________

I, hereby authorize UCP of Central Florida to request information on this child as indicated below.

Name of Child: Child’s Date of Birth:

Agency:

(Check all that apply)

4C/Early Head Start

Child Find (FDLRS)

Children’s Medical Services

County School District:

County Health Dept.:

Department of Children and Families

Division of Blind Services

Easter Seals

Early Steps/Part C

Pediatrician:

SSI

United Cerebral Palsy of

Other:

Types of information that may be shared:

(Check all that apply)

Psychological Testing

Social/Developmental History

Speech/Language and Hearing Reports

Vision/Hearing/Screening Results

Occupational/Physical Therapy Records

Developmental Assessment Reports

IFSP or IEP

Medical Information and Reports Including:

Medical Records

Immunizations

Physical Examinations Reports

Laboratory Reports

HIV Test Results

Other List:

Other:

I am aware that the information shared will be strictly confidential and cannot be released to anyone else without my written consent. I am aware that I may deny consent to any of the agencies listed above and that I may withdraw my consent at any time by notifying UCP of Central Florida in writing.

Signature of Parent or Legal Guardian Date

Witness Date

The execution of this form does not authorize the release of information other than that specifically described above.

The information requested on this form is solicited under Title 38, U.S.C. The form authorizes release of information in

accordance with the Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164, 5 U.S.C. 552a,

and 38 U.S.C. 5701 and 7332 that you specify.

for of 1

Date: Student Number:

To Whom It May Concern:

The following student has enrolled at our school. Please send all records including grades, courses taken, test scores, special education, psychological data, current individualized education plan (IEP), health records and immunization dates. Also, please include all grades earned this school year and/or withdrawal grades, if any.

Identifying Information

Student’s Name:

First

Date of Birth:

Middle Last

Parent(s)/Guardian(s) Name: Phone #:

Name of Last School Attended:

Complete Mailing Address of Last School Attended:

Street City State Zip

Phone # Fax #

Send Requested Records To:

Parent/Guardian Signature Date

For Principal or Records Clerk Only

Prior written consent of the parent or guardian of the student is not required to transfer records to schools in

which the pupil or student seeks or intends to enroll.

1st request

2nd request

3rd request

for of 2

Medical History

Child Name:

Pregnancy / Delivery

Pregnancy Proceeded Without Complications

With Complications

Eclampsia

Gestational Diabetes

Multiple Births

Polyhydramnios

Positive for Cytomegalovirus 'CMV'

Positive for Herpes

Positive for HIV

Positive for Strep B

Pre-eclampsia

Premature Labor

Substance Exposure

Toxemia

Other

Length of Pregnancy (in weeks) Prenatal care was Received Not Received

Delivery Proceeded Without Complications

With Complications

Abruptio Placenta

Breech Presentation

Low Birth Weight

Negative Vacuum

Non-progressive/unproductive Labor

Occiput Posterior Position (Face up)

Placenta Previa

Premature Rupture of Membranes

Transverse Presentation

Prolapsed Cord

Use of Forceps

Uterine Rupture

Umbilical Cord Wrapped Around Neck

Other

Delivery was Vaginal C-section Emergency C-section Length of child's hospital stay:

Mother's age at time of birth Birth Hospital

Needed to be transferred to another hospital Yes No

Transfer Hospital

Birth Weight Birth Height Apgar 1 min 5 min 10 min

Additional Comments

Multiple child pregnancies: # of live births: # of still births:

Additional details of birth

Complications Following Birth

Anemia of Prematurity

Bronchopulmonary Dysplasia 'BPD'

Cleft Lip

Cleft Palate Club

Foot

Cytomegalovirus

ECMO

Failure to Thrive

Hyperbilirubinemia

Intrauterine Growth Retardation 'IUGR'

IVH Bleed Grade I

IVH Bleed Grade II

IVH Bleed Grade III

IVH Bleed Grade IV

Jaundice treated by light therapy &/or blanket

Meconium Aspiration

Necrotizing Enterocolitis 'NEC'

Neonatal hypoxia

Oxygen dependency

PDA

Positive dependency

Respiratory Distress Syndrome

Respiratory Stridor

Respiratory Syncytial Virus 'RSV'

Retinopathy of Prematurity 'ROP'

Thrombocytopenia (Low Platelet count)

Ventilator Dependency

VP Shunt

Other

Diagnosed or Suspected Syndromes

Current Medications

Allergies

Current Vitamins, Herbs, Minerals, Homeopathics

Current Physicians

Diagnostic Tests

Hearing Test

Never Tested, No Concerns

Never Tested, Have Concerns

Normal Test Results

Abnormal Test Results

Last Test Date

Vision Test

Never Tested, No Concerns

Never Tested, Have Concerns

Normal Test Results

Abnormal Test Results

Last Test Date

Results

Concerns

Results

Concerns

Current Physicians

Name Specialty Reason Date of last visit

Diagnostic Tests

Test When Details/Results

Auditory Brainstem Response Biopsy Blood Work / Lab Tests Bone Density Scan CT Scan EEG EMG Lower GI Motility Study / Empty Scan MRI NCV Swallow Study Ultrasound Upper Endoscopy X-Ray

Surgeries and Procedures

Surgeries and Procedures

Type Date Results/Details

Does the child have: Allergies

Arteriovenous malformation (AVM)

Anoxic brain injury

Asthma/respiratory breathing problems

Autism

Baclofen Pump

Cerebral Palsy (CP)

Cerebral Vascular Accident (CVA)

Chronic Ear Infections

Other Medical Conditions

Orthopedic Conditions

Colic

Constipation

Diarrhea

Down Syndrome

Hip subluxation

Hydrocele

Laryngomalacia

Muscular Dystrophy

Osteoporosis

Periventricular Lukomalasia

Reflux

Scoliosis Degrees?

Seizure Condition

Sleep disorder

Sleep problems

Shunts

Torticollis

Traumatic brain injury (TBI)

Tube Feeding

Tubes in ears

Vagal Nerve Stimulator

None

Additional Comments

Is the child able to: Began at age (in months):

Developmental History

Is the child able to: Began at age (in months):

Bringing both hands to mouth

Buttoning pants/shirt

Come to sitting from a lying position

Creeping or crawling alone

Fully Toilet trained

Grabbing a toy

Holding head up alone

Pulling self to standing position

Rolling Over

Self-bathing

Self dressing

Sitting alone without support

Standing unsupported

Tying shoes

Walking with support

Walking unaided

Zipping/unzipping jacket

Is your child Right Handed Left Handed Neither

Concerns about handwriting? Yes No Describe:

How does child get around the house?

Favorite Toys / Play Activities

Description of Child

Active

Affectionate

Aggressive

Calm

Cautious

Curious

Demanding

Difficult to Comfort

Distractible

Fearful

Fearless

Fussy

Insecure

Motivated

Passive

Persistent

Playful

Shy

Stubborn

Withdrawn

Other:

Sensory processing & Regulation (please select all that apply)

Avoids getting messy

Seeks out (craves) touch or movement

Stumbles or falls frequently

Appears awkward or less coordinated

Flaps hands

Allows brushing of teeth

Bangs on surface, bangs/hits head

Fatigues quickly

Has self-abusive behaviors

Resists certain tasks or environment

Spins things or self

Is sensitive to lights,sounds or noise

Sleeps a lot

Resists touch

Walks on toes

Lines up toys or objects

Seeks out (craves) visually stimulating objects

Seeks out (craves) stimulating sounds

Resists certain movements (e.g. bouncing,

swinging, upside down)

Has difficulty figuring out how to move body or takes more time with movements

Does not tolerate certain textures (e.g. clothing,surfaces,foods)

Uses lots of pressure when touching someone or holding object

Has difficulty transitioning from one activity to another

Has difficulty falling asleep

Has difficulty remaining asleep through the night

Appears Lethargic/sleepy all the time

Has poor sense of body in space, runs into things

Seeks support for posture (e.g. leans on furniture, walls or

people, holds head)

Demonstrates stiff or rigid movement patterns

Hyperfocussed (on specific tasks, people, objects, etc.)

Other: please describe

Feeding Milestones

Communication Skills

Speech Milestones

Social/Emotional Skills

Is easily distracted

Calms self easily

Gets angry/frustrated easily

Is aggressive towards others

Prone to emotional outbursts

Doesn't allow others to join in play

Has difficulty making friends

Plays with peers

Only plays with adults

Prefers to play alone

Has difficulty with separations

Has poor eye contact

Feeding

Describe Any Feeding Problems

Other: please describe

Food Likes Food Dislikes

Feeding Milestones

When did the child begin? Age (in months) Milestone Age (in months)

Using a Bottle Using a Straw Using a Pacifier Stop Using a Bottle Eating baby food Stop Using a Pacifier Eating junior food Using Utensils to Eat Eating table food Holding own bottle/cup Drinking from a Cup Self-feeding Drinking from a Sippy Cup

Breast Feeding

# times currently breast fed per day Weaned from breast feeding at age:

Was never breast fed

Current Feeding Adaptations

Thickened Liquids: Consistency:

Adapted Utensils Details:

Adapted seating

Calorie supplements

Details:

Details:

Tube Feeding

Areas of Difficulty

Amount: Times per day: Continuous Bolus

Chewing

Communication Needs

Speech Language

Drooling

Swallowing

Transitioning Between Foods

Understanding Words

Jaw shifts/slides/juts

Communication Skills

Does the child: Yes No

Have speech that is understood by most people? Respond correctly to yes/no questions? Follow simple instructions? Respond when name is called? Stutter? Recognize objects, people, and places?

Speech Milestones

When did the child begin? Age (in months) Milestone Age (in months)

Babbling Putting 2 words together Saying first words Using short sentences Naming familiar objects

First Words

Augmentative Communication Device

Primary Communication

Methods of communication used:

Verbal Non-Verbal None

Vocalizations 2 word Phrases Facial Expressions Manual Sign Language Pointing

Single Words Complete Sentences Body Language Gestures Eye Gaze

Please describe current speech concerns:

Home Environment

Child lives with: (Please select all that apply)

Birth mother

Birth father

Adoptive mother

Adoptive father

Legal guardian

Please specify:

Step-mother

Step-father

Grandmother

Grandfather

Siblings

Please list siblings ages:

other relative

Please specify:

Additional Comments:

Adoption

Age at adoption:

Additional Details:

Type of Home

Single Level

2 Level

Ground Floor Apartment

Upper Level Apartment

Assisted Living Facility

Skilled Nursing Facility

Group Home

Other

Accessibility

# Stairs to get into home:

Ramp to get into home? Yes No

Handrail? Right Left

None

# Stairs in home: Handrail? Right Left None

Bathroom on Main Level

Bathroom on Upper Level

Bedroom on Main Level

Bedroom on Upper Level


Equipment Approx. Age Details Uses at Home Uses at School/Day Care

Therapy Services Type Status How often? Where?

Equipment presently used (Please select all that apply)

Equipment: Approx. Age Details Uses at Home Uses at School/Day Care

Braces Walker Stander Manual Wheelchair Power Wheelchair Hoyer Lift Weighted Vest Hand Splint(s) Track System Other:

Describe any home program that is currently performed (e.g. stretching, strengthening, brushing, etc)

Describe any community groups or sports activities the child is involved in

Grade in School Name of School

Does your child have an IFSP?

Yes No

Does your child have an IEP from school? Yes No

Has your child had a psychological or neuropsychological evaluation completed? Yes No

Therapy Services Type Status How Often? Where?

Assistive Technology Audiology Behavior Therapy Developmental History EI Services Intensive Suit Therapy Vision Therapy Nutrition Occupational Therapy Physical Therapy Social Therapy Speech / Language Therapy Developmental Follow-up Clinic Other:


Rev. 7/2016 JPS

PARENT RIGHTS: STUDENT RECORDS

As a parent, The Family Educational Rights and Privacy Act (FERPA) affords you certain rights with respect to your

student’s education records. These rights are:

1. The right to inspect and review the student’s education records within 45 days of the day the school receives arequest for access. You must submit a written request to the principal that identifies the record(s) you wish toinspect. The principal will make arrangements for access and notify you of the time and place where the records

may be inspected.

2. The right to request the amendment of the student’s education record that you believe is inaccurate or misleading.You must write the principal, clearly identify the part of the record you want changed, and specify why it isinaccurate or misleading. If the school decides not to amend the record as requested, the school will notify you orthe decision and advise you of your right to a hearing regarding the request for amendment.

3. The right to consent to disclosure of personally identifiable information contained in the student’s educationrecords, except to the extent that FERPA authorizes disclosure without consent. Once exception, which permitsdisclosure without consent, is disclosure to school officials with legitimate educational interests. A school official

is a person employed by the district as an administrator, supervisor, instructor, or school staff; the person electedto the school board; or, a person or company with whom the district has contracted to perform a specific task. Aschool official has a legitimate educational interest if the official needs to review an education record in order tofulfill his or her professional responsibility. Personally identifiable information will be released without consent toappropriate officials in emergency situations, to comply with a lawfully issued subpoena and in cases involvingcompulsory school attendance and child abuse.

4. The right to file a complaint with the U.S. Department of Education concerning alleged failures by the school to

comply with the requirements of FERPA. The address of the Office that administers FERPA is: Family Policy

RELEASE OF DIRECTORY INFORMATION

The School District may release the following “directory information” without your permission unless you notify the principal, in writing, within ten (10) calendar days of the receipt of this public notice.

Directory Information: Student’s name, address, grade level (if junior or senior), dates of attendance, participation in school sponsored activities and sports, weight and height of members of athletic teams, and awards and honors received. (Military recruiters may also obtain telephone numbers of high school students.)

Under the provisions of the Family Educational Rights and Privacy Act, you have the right to withhold the release of the directory information listed above. If you decide that you do not want the school to release the information listed above, any future requests for the “directory information” from individuals, organizations or other entities not

affiliated with the school or district will be refused. Please indicate here your request to withhold the items listed

above.

I do not want my child’s directory information released as described above.

Parent Name: Parent Signature:

Student Name: Grade: Date___________________

If the form is not received by the school principal within ten (10) calendar days, it will be assumed that the above information may be released for the remainder of the school year.

of Rights Records

The answers to this residency questionnaire help in determining eligibility of services that may be received through the federal McKinney-Vento Homeless Assistance Act 42 U.S.C. 11435. The OCPS MVP office: 407-317- 3485; www.homeless.ocps.net

Section A: Housing is Fixed, Regular, and Adequate

Please DO NOT complete this form, if you currently: • Rent/own your home OR Live with someone by choice (not due to financial hardship)

Section B: Housing is NOT Fixed, Regular, and Adequate (Complete all sections below and return to school)

Student(s) Current Nighttime Residence:

In an emergency/transitional shelter (A) Temporarily with another family due to loss of housing, economic hardship, or

similar reason (B) In a vehicle of any kind, trailer park or campground, abandoned building or

other substandard housing (D) � In a hotel/motel due to loss of housing, economic hardship, or similar reason (E)

How long have you been at this temporary residence? ________________________

Cause of Temporary Residence:

Foreclosure (M) Natural Disaster Type:

_____________________________ � Other: (Please Explain)

_____________________________

Section C: Student Information (All OCPS students including pre-school children living together as indicated above)

Student Name Student ID# M/F DOB Grade School

Current Street Address:_____________________________________________ City: _____________________ Zip: ______________

Contact Phone Number: _________________________________ Email: _________________________________________________

Name of Parent(s) / Legal Guardian(s): ________________________________________________________________________________

Section D: Unaccompanied Homeless Youth Must Complete This Section (U)

Student is living with an adult that is not a parent or legal guardian.

Caregiver Name: _____________________________________________________

Relationship to student: ________________ Phone: _____________________

Student is living alone without an adult.

How long has the student been living alone? _____________________________________

Additional protective rights and services may be available to qualified families. These rights include immediate school enrollment, free meals, school stability, and transportation to the school of origin (if over 2 miles).

� Please check if you allow this information to be released to social service agencies for possible assistance. Expires 6/30/18

The undersigned certifies that the information provided is accurate.

_________________________________________________________________________ ___________________________

Signature of Parent/Legal Guardian (OR) Unaccompanied Homeless Youth Date

Florida Statutes 837.06 provides that whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his official duty shall be guilty of a misdemeanor of the second degree.

Student Residency Questionnaire