New Student Registration 2019-2020

Students are required to bring the following documents to registration:

• Completed Registration Packet• Proof of Address (electric, water or gas bill; or lease under parent’s name)• Shot Records• Birth Certificate• Social Security Card• Last Report Card (current grade)• Parent or Guardian Picture Identification• STAAR Scores

Please contact Grace Casarez at 210-638-5900 if you have any questions.

Revised August 16, 2019

School Forms

1. AFIA Enrollment Form 2. Student Release of Information Form 3. Texas Public School Student/Staff Ethnicity and Race Data

Questionnaire 4. Student Health History Form 5. Special Programs Questionnaire 6. Request for Cumulative Records Form 7. Migrant Survey Form 8. Home Language Survey English/Spanish Form 9. Student Residency Questionnaire 10. Decision Record of “At Risk” Students 11. Free & Reduced Lunch Application English/Spanish 12. Photo Release Form 13. AFIA Volunteer Form 14. Field Trip Permission Form 15. Student Handbook Form (located on the last page

of this packet)

The parent, if answered yes on the student health survey form regarding severe allergy, food allergy, seizure, or asthma must complete the appropriate information forms identified below:

1. Allergen Meal Modification Request Form 2. Asthma Information/Action Plan Form 3. Seizure Information/Action Plan Form

Enrollment Form 2019-2020

Date of entry for student: __Grade: _______Age Sept. 1: __________

District in which you reside: District School

First Middle Last Suffix (i.e., Jr.)

Social Security Birth Date Birthplace Sex Ethnicity

Address Apt. # City State Zip

Parent/Guardian Relation Address City/State/Zip E-mail Home Phone Employer Work Phone

Parent/Guardian Relation Address City/State/Zip E-mail Home Phone Employer Work Phone

Emergency Contact Phone Relation Emergency Contact Phone Relation Emergency Contact must be 18 or older and be prepared to show picture ID. Doctor preference Phone Hospital preference Phone What type of health insurance does your child have? None Medicaid CHIP Private

Brother/Sister Grade School Brother/Sister Grade School

Dear Parent: This information is needed as a permanent school record of your child and will be used by school personnel. This is to certify the above information is correct.

I, the undersigned, do hereby authorize officials of the school to contact directly the person named on this form, and do authorize the above named physician to render such treatment as may be deemed necessary in an emergency, for the health of said child. In the event physician, other person on this form, or parents cannot be contacted, the school officials are hereby authorized to take whatever action is necessary in their judgment, for the health of the aforesaid child. I will not hold the school district responsible for the emergency care and/or transportation for said child.

Presenting false information or records for identification is a criminal offense under penal code 37.10. Enrolling a child under TUITION: The amount of expense required from local funds.

Parent/Guardian Signature Date

STUDENT RELEASE OF INFORMATION 2019-2020

Last Name First Name DOB Grade

Address City/State Zip Code

Parent/Guardian Name E-mail Address

Home Phone Mobile Phone Work Phone

Emergency Contact Name: Phone Number:

The Individuals listed below have my permission to pick my child up from school:

Print Complete Name

Relationship to Student

Telephone Number

Note: Your child will not be released to anyone who is not listed on this form. Please be aware that anyone on this list MUST have valid picture identification, such as a Driver’s License or Identification Card to pick up your child.

STUDENT RELEASE CHANGES WILL BE NOT BE ACCEPTED BY PHONE!

Parent Signature Date

Texas Education Agency Texas Public School Student/Staff Ethnicity and Race Data

Questionnaire The United States Department of Education (USDE) requires all state and local education institutions to collect data on ethnicity and race for students and staff. This information is used for state and federal accountability reporting as well as for reporting to the Office of Civil Rights (OCR) and the Equal Employment Opportunity Commission (EEOC).

School district staff and parents or guardians of students enrolling in school are requested to provide this information. If you decline to provide this information, please be aware that the USDE requires school districts to use observer identification as a last resort for collecting the data for federal reporting.

Please answer both parts of the following questions on the student’s or staff member’s ethnicity and race. United States Federal Register (71 FR 44866)

Part 1. Ethnicity: Is the person Hispanic/Latino? (Choose only one)

o Hispanic/Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

o Not Hispanic/Latino

Part 2. Race: What is the person’s race? (Choose one or more)

o American Indian or Alaska Native - A person having origins in any of the original peoples of North and South America (including Central America), and who maintains a tribal affiliation or community attachment.

o Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

o Black or African American – A person having origins in any of the black racial groups of Africa. o Native Hawaiian or Other Pacific Islander – A person having origins in any of the original peoples of

Hawaii, Guam, Samoa, or other Pacific Islands. o White – A person having origins in any of the original peoples of Europe, the Middle East, or North

Africa.

Student/Staff Name (please print) (Parent/Guardian)/ (Staff) Signature

Student/Staff Identification Number Date

Texas Education Agency – March 2010

Student Health History 2019-2020

Your child’s health history will help us assess any physical conditions which may require adjusting the school program. The information you record on this form will become a part of your child’s school health record and will remain confidential. Please complete the following information and return to Grace Casarez at (210) 638-5900.

Student’s name: Date of birth: Grade: Homeroom teacher: Parent’s name: Phone: Doctor’s name: Phone:

Does your child have, or has your child ever had: (Circle one and answer accordingly) Allergies to medication? Yes No Age of onset If yes, what? If yes, what kind of treatment? Food Allergies? Yes No Age of onset If yes, to what? If yes, what kind of treatment? Allergy to latex? Yes No Age of onset If yes, what kind of treatment? Other allergies? Yes No Age of onset If yes, to what? If yes, what kind? swelling around bite area only itching hives

swelling of lips or eyelids difficulty breathing other (give details)

If yes, what kind of treatment? (If immediate treatment of insect bite is required, send medication a physician’s protocol to school.) Asthma? Yes No If yes, what kind of treatment? Any seizure disorder? Yes No If yes, what kind? Age of onset If yes, what kind of treatment? Frequent fainting? Yes No If yes, what kind? Age of onset If yes, what kind of treatment? Severe injuries? Yes No If yes, what kind? Age of onset If yes, what kind of treatment? Operations or other hospitalizations? Yes No If yes, for what? Age of onset Headaches? Yes No If yes, what kind? Age of onset If yes, what kind of treatment?

Does your child have any physical restrictions? Yes No Does your child have health insurance? Yes No

Blood Pressure Problems? Yes No If yes, what kind? Age of onset If yes, what kind of treatment? Diabetes? Yes No If yes, what kind of treatment? Age of onset Active Tuberculosis? Yes No? Age of onset A positive skin test to tuberculosis? Yes No Reason for positive result: BCG Vaccine Exposure to Disease Heart Trouble? Yes No If yes, what kind? Age of onset If yes, what kind of treatment? Hyperactive behavior of Attention Deficit Disorder? Yes No If yes, age of onset? If yes, what kind of treatment? Emotional Problems? Yes No If yes, what kind? Age of onset If yes, what kind of treatment? Vision or eye problem? Yes No If yes, what kind? Age of onset If yes, what kind of treatment? Hearing problems or ear disease? Yes No If yes, what kind? Age of onset If yes, what kind of treatment? Headaches? Yes No If yes, what kind? Age of onset If yes, what kind of treatment? Bone or muscle problems? Yes No If yes, what kind? Age of onset If yes, what kind of treatment? Chronic dental problems? Yes No If yes, what kind? Age of onset If yes, what kind of treatment? Urinary or bladder problems? Yes No If yes, what kind? Age of onset If yes, what kind of treatment? Has your child ever had chicken pox? Yes No Date of Illness Other medical problems not yet asked? Yes No If yes, what kind? If yes, what kind of treatment?

Does your child take any medications routinely? Yes No Name of Medication Dosage How often? To be taken at school?

If yes, which type: Medicaid Chip Other Private Insurance? This authorizes school personnel to release pertinent information to appropriate personnel, health care providers and educational agency (s).

Parent signature: Date

Special Needs Questionnaire 2019-2020

In order to provide your child an educational program that meets his or her needs, we need the following information. It is important for us to know if your child has received any special education services in the past. The fact that your child has been in a special education program will not affect his/her enrollment at our charter school. In fact, it will aid us in serving your child in the best possible way. The information you provide will be kept confidential:

Child’s Name:

School last attended: Grade

Address of school last attended:

Previous School Attended:

Please answer the following: • Is your child in a Dyslexia program at their current school? Yes No

•

Does your child receive services under Section 504?

Yes

No

• Is your child in a Bilingual, English as a Second Language (ESL) or Dual Language Program? Yes No

• Has your child been placed in a special education program? Yes No

• If no, is your child in the process of being referred for Special Education services?

Yes No

• Does your child receive Speech Therapy at their current school? Yes No

Do you have any concerns about your child’s school performance? Check any statement that applies to your child:

• Have they ever been retained? • May need extra help in reading? • May need extra help in math? • May need extra help in writing? • Sometimes has a difficult time getting along with other people? • Has a difficult time focusing? • Sometimes has difficulty sitting still? • Becomes frustrated with school work?

This information I have given is correct to the best of my knowledge. Parent Signature: Date:

Request for Cumulative Records

2019-2020

Name of Student: Date of Birth: Grade:

Information About Previous School

• Last School Attended • Address of School • Phone No. of School

In accordance with the Family Education Rights and Privacy Act (the Buckely Amendment) Subpart 3, Section 99.31 and 99.34 educational records of students may be transferred between schools without a signed release.

AFIA Staff Only Request: 1st ; 2nd ; 3rd ; Records Rec’d

Phone Contact Notes Date: Person spoke with:

Phone Contact Notes Date: Person spoke with:

Migrant Survey 2019-2020

Student Name Date

Address City/State/Zip

Home Phone Cell Grade

Your child may qualify for supplemental services at AFIA if they meet certain qualifications. To help us, please answer the following questions:

1) Have you or your family moved within the last 3 years to find seasonal or

temporary work? Yes No

For example: A. Picking onions, pecans, cotton, etc.; Yes No B. Packing fresh vegetables, fruits, poultry, or mushrooms; Yes No C. Catching or processing fish. Yes No

2) Did the family cross a school district boundary looking for temporary or

seasonal work in agriculture or fishing activities? Yes No Parent/Guardian Signature

LPAC Framework Manual 2018-2019 Texas Education Agency

INSPIRE ACADEMIES CHARTER DISTRICT

HOME LANGUAGE SURVEY-19 TAC Chapter 89, Subchapter BB, §89.1215

(Home Language Survey applicable ONLY if administered for students enrolling in pre-kindergarten through grade 12)

TO BE COMPLETED BY PARENT OR GUARDIAN FOR STUDENTS ENROLLING IN PREKINDERGARTEN THROUGH GRADE 8 (OR BY STUDENT IN GRADES 9-12): The state of Texas requires that the following information be completed for each student who enrolls in a Texas public school for the first time. It is the responsibility of the parent or guardian, not the school, to provide the language information requested by the questions below.

NAME OF STUDENT: ______________________________ STUDENT ID#: _______________________________ ADDRESS: _______________________________________ TELEPHONE #: _______________________________ CAMPUS: ________________________________________

NOTE: PLEASE INDICATE ONLY ONE LANGUAGE PER RESPONSE.

1. What language is spoken in the child’s home most of the time? ________________________ 2. What language does the child speak most of the time? ________________________

_______________________________________ ________________________________ Signature of Parent/Guardian Date

_______________________________________ ________________________________ Signature of Student if Grades 9-12 Date NOTE: If you believe you made an error when completing this Home Language Survey, you may request a correction, in writing, only if: 1) your child has not yet been assessed for English proficiency; and 2) your written correction request is made within two calendar weeks of your child’s enrollment date.

Dear Parent or Guardian: To determine if your child would benefit from Bilingual and/or English as a Second Language program services, please answer the two questions below. If either of your responses indicates the use of a language other than English, then the school district must conduct an assessment to determine how well your child communicates in English. This assessment information will be used to determine if Bilingual and/or English as a Second Language program services are appropriate and to inform instructional and program placement recommendations. If you have questions about the purpose and use of the Home Language Survey, or you would like assistance in completing the form, please contact your school/district personnel. For more information on the process that must be followed, please visit the following website: https://projects.esc20.net/upload/page/0084/docs/EL%20Identification_ReclassificationFlowchart%202018.pdf

This survey shall be kept in each student’s permanent record folder.

Student Residency Questionnaire 2019-2020

This questionnaire is intended to address the McKinney-Vento Homeless Education Assistance Improvements Act 42 U.S.C. 11435. The answers to this residency information help determine the services the student may be eligible to receive.

Student Name Grade Date

Birth Date: Age Social Security Number

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

Address Zip Phone

1. Is your current address a temporary living arrangement? Yes No

2. Is this temporary living arrangement due to loss of housing or economic hardship? Yes No

If you answered YES to questions 1 and 2, please complete the remainder of this form.

If you answered NO, you may stop here. Please Sign: Parent/Guardian Signature

Where is the student presently living? Circle one of the choices below:

In a motel In a shelter With more than one family in a house or apartment Moving from place to place In a place not designed for ordinary sleeping accommodations such as a car, park or campsite

Signature of Parent/Legal Guardian Date Presenting a false record of falsifying records in an offense under Section 37.10, Penal code, and enrollment of the child under false documents subjects the person to liability for tuition or other costs. TEX Sec. 25.002 (3) (d)

I certify the above named student qualifies for the Child Nutrition Program under the provisions of the McKinney-Vento Act.

Date McKinney-Vento Liaison Signature

Decision Record of “At Risk” Students 2019-2020

Student’s Legal Name (First, Middle, Last) DOB

Pursuant to section 29.081 (b) of the Texas Education Code (TEC), school districts in Texas are required to provide accelerated instruction to students who are at risk of dropping out of school. Additionally, school districts are required to evaluate and document the effectiveness of the accelerated instruction in reducing the dropout rate and in increasing achievement of students who are at risk of dropping out of school.

House Bill 7 passed during the 85th Legislature session 2017, modified the criteria for identifying a student as “at risk of dropping out of school”:

For purpose of this section, students at risk of dropping out of school include each student who is under 21 years of age and who:

Was not advanced from one grade level to the next for two or more school years; Did not maintain, for students enrolled in grades 7-12, an average equivalent to 70 on a scale of 100

in two or more subjects in the foundation curriculum during a semester in the preceding or current school year or is not maintaining such an average in two or more subjects in the foundation curriculum in the current semester;

Did not perform satisfactorily on an assessment instrument administered to the student under Subchapter 8, Chapter 39, and who has not in the previous or current school year subsequently performed on that instrument or another appropriate instrument at a level equal to at least 110 percent of the level of satisfactory performance on that instrument;

Is Pregnant or is a parent;

Has been placed in an alternative education program in accordance with Section 37.006 during the preceding or current school year;

Has been expelled in accordance with Section 37.007 during the preceding or current school year; Is currently on parole, probation, deferred prosecution, or other conditional release; Was previously reported through the Public Education Information Management System (PEIMS) to

have dropped out of school; Is a student of limited English proficiency as defined by Section 29.052; Is in the custody or care of the Department of Family and Protective Services or has, during the

school year, been referred to the department by a school official, officer of the juvenile court, or law enforcement official;

Is homeless as defined by 42 USC Section 11302, and its subsequent amendments; or Resided in the preceding school year or reside in the current school year in a residential placement

facility in the district, including a detention facility, substance abuse treatment facility in the district, including a detention facility, emergency shelter, psychiatric hospital, halfway house, cottage home operation, specialize child -care home, or general residential operation.

X Caseworker/Parent/Guardian Signature Date

June 26, 2019

BRAINATION Anne Frank Inspire Academy, 2019-2020 Standard (Multi-Child) Application for Free and Reduced-Price School Meals

Complete one application per household. Please use a pen (not a pencil). Apply online @ family.titank12.com

This Box for School Use Only.

Date Withdrawn:

Step 1: Definition of Household Member: anyone who is living with you and shares income and expenses, even if not related. Children in Foster care; children who meet the definition of Homeless, Migrant, or Runaway or who participate in Head Start are eligible for free meals. Please read the directions for more information.

A. List ALL Household Members Who Are Infants, Children, and Students up to and Including Grade 12. If more spaces are needed, use the Additional Names section on the back.

List each child’s name. Student Attends School in District?

Grade Optional: Student

ID Number

Check all that apply.

First Name MI Last Name Yes No Foster Head Start Homeless Migrant Runaway

1.

2.

3.

4.

B. Participation in a Categorical Program

• If every child listed in Step 1 is a participant any one of the following programs—Foster, Head Start, Homeless, Migrant, or Runaway, skip Step 2 and complete Step 3.

• SNAP, TANF, or FDPIR: Do any Household Members (including you) currently participate in SNAP, TANF, and/or FDPIR?

If No, complete Steps 2 and 3. If Yes to SNAP/TANF > Write the Eligibility Determination Group (EDG) number in this space ____________________, skip Step 2, and complete Step 3.

If Yes to FDPIR, check this box , skip Step 2, and complete Step 3.

Step 2: Please read the directions for more information for the following questions.

Report Income for ALL Household Members (Skip this step if you entered an EDG number or checked the box to indicate participation in FDPIR in Step 1).

A. Last Four Digits of Social Security Number (SSN) of an Adult Household Member: XXX-XX __ __ __ __ Check if no SSN

B. Income for Adult Household Members (Include Yourself, But Not Children. If more spaces are needed, use the Additional Names section on the back.)

List all Household Members not listed in STEP 1 (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report total income (without deductions) for each source in whole dollars only. Indicate the frequency of income: W=Weekly, E=Every 2 Weeks, T=Twice per Month, M=Monthly, A=Annually. If they do not receive income from any source, write ‘0.’ If you enter ‘0’ or leave any fields blank, you are certifying (promising) that there is no income to report.

Adult’s First/Last Name (Do not include the income of children in this section. The income of children goes in 2D.)

Work Earnings

(Enter Amount)

Frequency

(Circle One)

Public Assistance/ Child Support/ Alimony

(Enter Amount)

Frequency

(Circle One)

Pensions/Retirement/ Social

Security/SupplementalSecurity Income

(Enter Amount)

Frequency

(Circle One)

All Other

(Enter Amount)

Frequency

(Circle One)

1. $ W–E–T–M–A $ W–E–T–M–A $ W–E–T–M–A $ W–E–T–M–A

2. $ W–E–T–M–A $ W–E–T–M–A $ W–E–T–M–A $ W–E–T–M–A

3. $ W–E–T–M–A $ W–E–T–M–A $ W–E–T–M–A $ W–E–T–M–A

C. Income for Children in the Household (Do not include adult income. Do report any type of regular income for children in the household. If more spaces are needed, use the Additional Names section on the back.)

Record total income by frequency for each child who receives regular income listed in Step 1. Weekly Every 2 Weeks Twice per Month Monthly Annually

1. $ $ $ $ $

2. $ $ $ $ $

3. $ $ $ $ $

D. Total Household Members (Count all children & adults living in the household) _____

Step 3: Please read the directions for more information on signing this form.

Provide Contact Information and Adult Signature. Return this application to insert mailing address, fax number, email, and/or return to your child’s school.

I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of Federal funds, and that school officials may verify (check) the information. I am aware that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted under applicable State and Federal laws.

Street Address/Apt # City State Zip Daytime Phone and Email (Optional)

Printed Name of Adult Household Member Signing the Form Signature of Adult Household Member Signing the Form Today’s Date

June 26, 2019

Step 1: Additional Names

A. List ALL Household Members Who Are Infants, Children, and Students up to and Including Grade 12. If more spaces are needed, use the Additional Household Member Sheet on the back.

List each child’s name. Student Attends School in District?

Grade Optional: Student

ID Number

Check all that apply.

First Name MI Last Name Yes No Foster Head Start Homeless Migrant Runaway

5.

6.

7.

8.

9.

Step 2: Additional Names

B. Income for Adult Household Members (Include Yourself, But Not Children)

Adult’s First/Last Name (Do not include the income of children in this section. The income of children goes in 2D.)

Work Earnings

(Enter Amount)

Frequency

(Circle One)

Public Assistance/ Child Support/ Alimony

(Enter Amount)

Frequency

(Circle One)

Pensions/Retirement/ Social

Security/Supplemental

Security Income

(Enter Amount)

Frequency

(Circle One)

All Other

(Enter Amount)

Frequency

(Circle One)

4. $ W–E–T–M–A $ W–E–T–M–A $ W–E–T–M–A $ W–E–T–M–A

5. $ W–E–T–M–A $ W–E–T–M–A $ W–E–T–M–A $ W–E–T–M–A

6. $ W–E–T–M–A $ W–E–T–M–A $ W–E–T–M–A $ W–E–T–M–A

C. Income for Children in the Household (Do not include adult income. Do report any type of regular income for children in the household.)

Record total income by frequency for each child who receives regular income listed in Step 1. Weekly Every 2 Weeks Twice per Month Monthly Annually

1. $ $ $ $ $

2. $ $ $ $ $

3. $ $ $ $ $

The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the last four digits of the social security number of the adult household member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov.

This institution is an equal opportunity provider.

Do Not Fill Out This Part. This Is For School Use Only.

Income Determination: Multiple income frequencies must be converted to annual amounts and combined to determine household income. Do not convert if only one income frequency is provided by the household. If converting income to annual, round only the final number—Annual Income Conversion: Weekly x 52 | Every 2 Weeks x 26 | Twice a Month x 24 | Monthly x 12

Date Received:

Categorical Determination

Eligibility:

Household Size: _____ Total Income: ______________ Weekly

Every 2 Weeks

Twice a Month

Monthly

Annually

Free

Reduced

Denied

Reviewing/Determining Official’s Signature/Date Confirming Official’s Signature/Date

June 26, 2019

BRAINATION Anne Frank Inspire Academy, Solicitud Estándar (para Varios Niños) para Comidas Escolares Gratuitas y a Precio Reducido para del 2019-2020

Llene una solicitud para cada hogar. Favor de usar un bolígrafo (no un lápiz). Llene su solicitud por internet al https://family.titank12.com//4842RJ

This Box for School Use Only.

Date Withdrawn:

Parte 1: Definición de Miembro del hogar: Una persona que vive con usted y comparte los ingresos y los gastos, aunque no estén relacionados. Los niños temporalmente adoptados (foster), niños que satisfacen la definición de migrantes, sin hogar, (homeless), fugitivo, (runaway), o que participan en Head Start son elegibles para alimentos gratis. Por favor, lea las instrucciones para obtener más información.

A. Liste a TODOS los Miembros del Hogar, Infantes, Niños y Estudiantes hasta el Grado 12. Si necesita más espacio, usen la sección de nombre adicional en parte de atrás de la página.

Liste el nombre de cada niño. ¿Asiste a la escuela en el distrito?

Grado

Opcional: Número de Identificación del Estudiante

Marque todo lo que aplique.

Primer Nombre Inicial del Segundo Nombre

Apellido Sí No Niño Adoptivo

Temporal (Foster)

Head Start Sin Hogar Migrante Fugitivo

1.

2.

3.

4.

B. Participación en las Diferentes Categorías de Elegibilidad

• Si todos los niños indicados en la Parte 1 participan en un programa de la lista arriba, ignore las Partes 2, y pase directamente a la Parte 3.

• ¿Recibe algún miembro del hogar (incluya a usted mismo) beneficios de los programas de asistencia: SNAP, TANF, o FDPIR?

No> Complenté 2 y 3. Si > Escriba el número de Determinación de Elegibilidad (EDG, por sus siglas en inglés) en este espacio ______________________, y pase directamente a la Parte 3.

SI > FDPIR, marque en la casilla , ignore las Partes 2, y pase directamente a la Parte 3.

Parte 2: Lea las instrucciones para obtener más información para las siguientes preguntas.

Declare el Ingreso de TODOS los Miembros del Hogar (Ignore este parte si escribió un número de EDG en la Parte 2).

A. Los últimos cuatro números del Seguro Social (SSN) del miembro del hogar que llenó lasolicitud: XXX-XX __ __ __ __ Marque aquí si no tiene un SSN

B. Ingresos (Brutos) de los Adultos del Hogar (incluya a usted mismo, pero no los menores). Si necesita más espacio, usen la sección de nombre adicional en parte de atrás de la página.

Liste a todos los Miembros del Hogar que no son listados en la Parte 1 (incluya a usted mismo) incluso si no reciben ingresos. Para cada Miembro del Hogar indicado que recibe ingresos, anote el ingreso (sin deducciones) total de cada fuente en dólares redondeados. Ponga la frecuencia en que recibe su ingreso: W=Semanal, E=Cada 2 semanas, T=2 veces por mes, M=Mensual, A=Anualmente. Si la persona no recibe ingreso, escriba ‘0.’ Si escribe ‘0’ o deja algún espacioen blanco, está certificando (prometiendo) que no hay ingreso para reportar.

Primer Nombre del Adulto/ Apellido (No incluya los ingresos de los niños en esta sección. Los ingresos de los menores se anota en 2D)

Sueldo de Trabajo

(Ponga el monto)

Frecuencia

(Marque la frecuencia con

un círculo)

Asistencia Social/ Manutención de niños /

Pensión alimenticia (Ponga el monto)

Frecuencia

(Marque la frecuencia con un

círculo)

Pensiones/Jubilación/ Seguro social/ SSI

(Ponga el monto)

Frecuencia

(Marque la frecuencia con un

círculo)

Otros Ingresos

(Ponga el monto)

Frecuencia

(Marque la frecuencia con

un círculo)

1. $ W–E–T–M–A $ W–E–T–M–A $ W–E–T–M–A $ W–E–T–M–A

2. $ W–E–T–M–A $ W–E–T–M–A $ W–E–T–M–A $ W–E–T–M–A

3. $ W–E–T–M–A $ W–E–T–M–A $ W–E–T–M–A $ W–E–T–M–A

C. Ingresos (Brutos) de los Niños del Hogar (No incluya los ingresos de los adultos.) Si necesita más espacio, usen la sección de nombre adicional en parte de atrás de la página.

Liste el ingreso regular por la frecuencia para cada niño que recibe ingreso que listado en el Parte 1. Semanal Cada dos semanas Dos veces por me Mensual Anualmente

1. $ $ $ $ $

2. $ $ $ $ $

3. $ $ $ $ $

D. Total de los miembros del hogar (Cuente todos los niños y adultos que viven en el hogar.) _____

Parte 3: Lea las instrucciones para obtener más información sobre cómo firmar este formulario.

Proporcione Su Información de Contacto y Firma de Adulto. Regrese esta solicitud a: Insert mailing address, fax number, email, and/or return to your child’s school.

Certifico (juro) que toda la información en esta solicitud es cierta y que he reportado todos los ingresos. Entiendo que esta información se da con el propósito de recibir fondos federales y que los funcionarios de la escuela pueden verificar tal información. Entiendo que si falsifico información a propósito, mis hijos pueden perder los beneficios de comida y que puedo ser procesado de acuerdo con las leyes estatales y federales que aplican.

Dirección/Apt. Ciudad Estado Código Postal Número de teléfono y correo electrónico (opcional)

Miembro (Adulto) del hogar que lleno solicitud Firma del adulto que llenó la solicitud Fecha de hoy

June 26, 2019

Parte 1: Nombres Adicional

Liste a TODOS los Miembros del Hogar, Infantes, Niños y Estudiantes Hasta el Grado 12.

Liste el nombre de cada niño. ¿Asiste a la escuela en el distrito?

Grado

Opcional: Número de Identificación del

Estudiante

Marque todo lo que aplique.

Primer Nombre Inicial del Segundo Nombre Apellido Sí No Niño Adoptivo

Temporal (Foster) Head Start Sin

Hogar Migrante Fugitivo

4.

5.

6.

Parte 2: Nombres Adicional

B. Ingresos (Brutos) de los Adultos del Hogar (incluya a usted mismo, pero no los menores).

Primer Nombre del Adulto/ Apellido (No incluya los ingresos de los niños en esta

sección. Los ingresos de los menores se anota en 2D)

Sueldo de Trabajo

(Ponga el monto)

Frecuencia

(Marque la frecuencia con

un círculo)

Asistencia Social/ Manutención de niños /

Pensión alimenticia (Ponga el monto)

Frecuencia

(Marque la frecuencia con un

círculo)

Pensiones/Jubilación/ Seguro social/ SSI

(Ponga el monto)

Frecuencia

(Marque la frecuencia con un

círculo)

Otros Ingresos

(Ponga el monto)

Frecuencia

(Marque la frecuencia con

un círculo)

4. $ W–E–T–M–A $ W–E–T–M–A $ W–E–T–M–A $ W–E–T–M–A

5. $ W–E–T–M–A $ W–E–T–M–A $ W–E–T–M–A $ W–E–T–M–A

6. $ W–E–T–M–A $ W–E–T–M–A $ W–E–T–M–A $ W–E–T–M–A

C. Ingresos (Brutos) de los Niños del Hogar (No incluya los ingresos de los adultos.) Si necesita más espacio, usen la sección de nombre adicional en parte de atrás de la página.

Liste el ingreso regular por la frecuencia para cada niño que recibe ingreso que listado en el Parte 1. Semanal Cada dos semanas Dos veces por mes Mensual Anualmente

4. $ $ $ $ $

5. $ $ $ $ $

6. $ $ $ $ $

La Ley Nacional de Alimentos Escolares Richard B. Russell pide la información arriba en esta solicitud. No tiene que dar la información, pero si usted no la provee, no podemos aprobar comida gratuita o de precio reducido para sus niños. Usted debe incluir los últimos cuatro números del Seguro Social (SSN) del adulto que firma la solicitud. Los últimos cuatro números del SSN no se requieren cuando usted solicita de parte de un niño adoptivo temporal o usted incluye un número de caso del Programa de Asistencia Nutricional Suplementaria (SNAP, por sus siglas en inglés), el Programa de Asistencia Temporal Para Familias Necesitadas (TANF, por sus siglas en inglés) o el Programa de Distribución de Comida en Reservaciones Indígenas (FDPIR, por sus siglas en inglés) u otra identificación FDPIR de su niño. Tampoco necesita indicar el número del SSN si el adulto del hogar que firma la solicitud no tiene. Utilizamos su información para determinar si su niño es elegible para la comida gratuita o de precio reducido, y para administrar y hacer respetar los programas de almuerzo y desayuno. Podemos compartir la información sobre su elegibilidad con los programas de educación, salud, y nutrición para ayudarles a evaluar, financiar, o determinar los beneficios de sus programas, así como con los auditores de revisión de programas, y los oficiales encargados de investigar violaciones del reglamento programático.

De conformidad con la Ley Federal de Derechos Civiles y los reglamentos y políticas de derechos civiles del Departamento de Agricultura de los EE. UU. (USDA, por sus siglas en inglés), se prohíbe que el USDA, sus agencias, oficinas, empleados e instituciones que participan o administran programas del USDA discriminen sobre la base de raza, color, nacionalidad, sexo, discapacidad, edad, o en represalia o venganza por actividades previas de derechos civiles en algún programa o actividad realizados o financiados por el USDA. Las personas con discapacidades que necesiten medios alternativos para la comunicación de la información del programa (por ejemplo, sistema Braille, letras grandes, cintas de audio, lenguaje de señas americano, etc.), deben ponerse en contacto con la agencia (estatal o local) en la que solicitaron los beneficios. Las personas sordas, con dificultades de audición o discapacidades del habla pueden comunicarse con el USDA por medio del Federal Relay Service [Servicio Federal de Retransmisión] al (800) 877-8339. Además, la información del programa se puede proporcionar en otros idiomas. Para presentar una denuncia de discriminación, complete el , (AD-3027) que está disponible en línea en: http://www.ascr.usda.gov/complaint_filing_cust.html y en cualquier oficina del USDA, o bien escriba una carta dirigida al USDA e incluya en la carta toda la información solicitada en el formulario. Para solicitar una copia del formulario de denuncia, llame al (866) 632-9992. Haga llegar su formulario lleno o carta al USDA por: (1) correo: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; o (3) correo electrónico: program.intake@usda.gov. Esta institución es un proveedor que ofrece igualdad de oportunidades.

Do Not Fill Out This Part. This Is For School Use Only.

Income Determination: Multiple income frequencies must be converted to annual amounts and combined to determine household income. Do not convert if only one income frequency is provided by the household. If converting income to annual, round only the final number—Annual Income Conversion: Weekly x 52 | Every 2 Weeks x 26 | Twice a Month x 24 | Monthly x 12

Date Received:

Categorical Determination

Eligibility:

Household Size: _____ Total Income: ______________ Weekly

Every 2 Weeks

Twice a Month

Monthly

Annually

Free

Reduced

Denied

Reviewing/Determining Official’s Signature/Date Confirming Official’s Signature/Date

Da

Photo Release Form 2019-2020

Permission to Use Student’s Photograph

During the course of the academic year, Anne Frank Inspire Academy may wish to use photographs/video of AFIA students on school bulletin boards, and in educational publications, school videos, yearbook photographs, individual classroom website pictures or in general media releases on a controlled basis. Any such photographs would highlight the student(s) either demonstrating learning techniques or participating in approved school activities.

In accordance with school policy, names of individual students will not be released with any photographs.

Student’s Name:

I/We consent to the use of my child’s image; such use may include all AFIA Publications (print, online, video, etc.). Such photographs would highlight the students either demonstrating learning techniques or participating in approved school activities.

I/We DO NOT consent to the use of my child’s image ever; this use includes all AFIA Publications (print, online, video, etc.).

Parent/Guardian’s signature

Parent/Guardian’s signature

Email address

Phone number

AFIA Volunteer Form

2019-2020

Name:________________________________________ Phone:_________________________________ Email:____________________________________________________________________ In order to create the best AFIA experience possible for everyone, volunteer help is essential. Please mark all areas for which you are willing to serve: ______ Network with people and businesses to support the AFIA program (wall of honor, naming rights, etc.). ______ Promote and facilitate membership in AFIA Booster Clubs. ______ Help prepare for school events and field trips, organize paperwork, input information in the computer, make phone calls, chaperone trips or assist in the AFIA office on occasion. ______ Coordinate meals on occasion for special presenters throughout the year, give school tours, assist with community thank-you events, etc. ______ Seek out opportunities to promote the AFIA student leaders. ______ Help to increase membership for the booster clubs, and coordinate necessary forms for membership. ______ Organize fundraisers throughout the school year. ______ Coordinate t-shirt orders for our spirit shirts. Organize and fill the orders throughout the school year. ______ Assist with promoting AFIA. Use social media to promote AFIA. ______ Other

AFIA volunteers provide support to the school program and activities. Activities include fundraising, publicity, and communication with the school and community.

We look forward to hearing from you!

FIELD TRIP PERMISSION

I, _____________________________ (parent/guardian), agree to allow my son or daughter, (student’s name), to attend all field trips or out of school activities for the 2019-2020 school year.

This is to certify that I authorize the Head of School or a designated representative to secure any and all emergency medical care and treatment for my child for acute illnesses suffered or injury sustained while participating on these trips or activities. I understand that, while student safety is a high priority for The Anne Frank Inspire academy, under state law, the school is not responsible for medical costs associated with student injury.

In consideration for my child’s participation in field trips or activities, I expressly hold harmless from and waive against The Anne Frank Inspire Academy, it’s administration, faculty and staff any and all claims for medical expenses, loss of services, injury to person or property, death, or other claims, actions or liabilities made against it or them on behalf of my child, regardless of the cause of such claims, actions or liabilities, or any concurrent or contributing fault or negligence of it or them as such may result from my child’s participation in these trips or activities.

In further consideration for my child’s participation in the above described field trip or activity, I also agree to indemnify and hold harmless The Anne Frank Inspire Academy, damages, claims, or liabilities of any character, type or description, including attorney’s fees and court costs, made by third parties against it or them which may result from my child’s participation in these trips or activities.

I understand that The Anne Frank Inspire Academy, its administration, faculty and staff are not waiving any sovereign or governmental immunity which it or they have under Texas law.

I have read and understand this release and sign it voluntarily and with full knowledge of its significance. Signature of Parent/Guardian: ____________________________ Date:

Daytime Phone: _________________________________

Emergency Contact: _________________________________

Home Phone: _________________________________

ALLERGEN MEAL MODIFICATION FORM

The school meal modification request must be submitted to the School District yearly by the parent or guardian. This form must be completed and signed by a Licensed Medical Authority (Physician, Physician Assistant or Advance Practice Nurse).

Student Legal Name - Last: First: Middle Initial:

Date of Birth: Student ID # School: Grade :

1) Does this student have a disability? Yes _ No _

Under Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act (ADA) of 1990, and the ADA Amendments Act of 2008, a “person with a disability” is any person who has a physical or mental impairment that substantially limits one or more major life activities, has a record of such an impairment or is regarded as having such an impairment.

2) Condition/Diagnosis that requires a special diet or food modification at school: _ __

_

• If needed allergy-freindly seating will be available during meals.

3) Check the food allergen(s) to be omitted from the child’s diet or the no substitution needed box. Review the foods that are recommended substitutions. The most common food allergies are peanut, tree nut, milk, egg, seafood, shellfish, soy and wheat. Space is provided at the end of the form for additional foods to omit.

No Substitution Needed

Peanut/Tree Nut Allergy Diet Restriction Substitution Could Include Common School Items: A few prepackaged snack items processed in a facility that contains tree nuts

No nut products Nut Free snack

Milk Allergy ( lactose intolerant) Diet Restriction Substitution Could Include Common School Items: Milk, yogurt, ranch dressing cheese products, some breaded entrees, entrée salads, ice cream, pudding, some bread products

No milk products Restricts all dairy products

Alternate food items available most days.

Egg Product Allergy – restricts eggs in baked items, mayonnaise based and breaded meat items

Diet Restriction Substitution Could Include

Common School Items: Breaded meat items, mayonnaise products, French toast, cinnamon rolls

No egg products Alternate menu entrée choice of the day

If yes, check the major life activities affected by the disability and reason the disability prevents the child from eating the regular school meal.

breathing ; eating ; hearing ;learning ; seeing ; speaking ; walking ;

performing manual tasks ; caring for one’s self

ALLERGEN MEAL MODIFICATION FORM

Egg Allergy - allows eggs in baked items, mayonnaise based and breaded meat items

Diet Restriction Substitution Could Include

Common School Items: Eggs (breakfast taco) No eggs Alternate menu entrée choice of the day Cereal or Breakfast Bar/Pastry

Fish (seafood, shellfish) Diet Restriction Substitution Could Include Common School Items: Fish No fish Alternate entrée choice of the day

Soy Allergy – most of our food Diet Restriction Substitution Could Include Common School Items: Soy oil: Most bread items fried rice, most entrees, salad dressings, ranch dip, packaged snacks, gravy Soy protein: Most entrees, egg rolls, soy milk, soy sauce

No soy Parents should contact Rebecca McCaw @ 832-423-0779 or rebecca.mccaw@foodservicepeeps.com to discuss alternative menu choices.

Wheat Allergy (Wheat, Rye, Barley Oats) Diet Restriction Substitution Could Include Sandwich bread/buns, rolls, flour tortillas, crackers, croutons breaded meat items, pizza, pizza sticks, corndogs, pasta, pretzels, spicy hash browns, potato wedges, gravy, soy sauce, breakfast cereal, some breakfast entrees, cookies, cereal bars, some ice cream products

No wheat/oat products Parents should contact Rebecca McCaw @ 832-423-0779 or rebecca.mccaw@foodservicepeeps.com to discuss alternative menu choices.

Foods to omit that are not already listed Suggested Foods to Substitute (Some substitutions recommended may not be available)

Medical Authority Name (print):

Medical Authority Signature: Date:

Address: _ Phone Number:

I understand that if my child’s medical or health needs change, it is my responsibility to notify the school and fill out a new Special Diet Request. Parent/guardian must submit a request in writing or email to remove diet restriction.

Student Legal Name - Last: First: Middle Initial:

Parent/Guardian Name (print):

Address:

Parent/Guardian Phone Number Email:

Parent/Guardian Signature: Date

In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800)845-6136 (Spanish). USDA is an equal opportunity provider and employer.

Anne Frank Inspire Academy - ASTHMA ACTION PLAN

HB 1688 allows students to self-administer asthma medications while at school or school functions with permission from parents and physicians.

(This form is to be completed at the beginning of each school year and kept on file in the Head of School’s office)

Student:____________________________________ DOB:__________ Grade:_______ School Year: Advisor:___________________

Parent/Guardian Address: Phone Numbers: Home: Work: Emergency Contact Name: Relationship: Phone: Physician student sees for asthma treatment: Phone: List any other Physician(s) that treat your child: Please list all Current Medications

Medication Name Dosage Time

Medications to be Given at School

Medication Purpose Dosage When to use Can be repeated for severe breathing difficulty

Times: Minutes apart:

Times: Minutes apart:

If any of the signs below are noted, then follow the emergency plan: • Struggling to breathe, chest retracting, hunched over while breathing, trouble walking or talking, stops playing

and cannot start activity again, or lips or fingernails turn gray or blue. EMERGENCY PLAN • Give rescue medication (bronchodilator) and repeat times minutes apart. • If no improvement is noted within 15 minutes after the first treatment call 911.

I have instructed (student’s name) in the proper way to use his/her medications, and it is my professional opinion that (student’s name) should be allowed to carry and self-administer the following medications while on school property or at school-related events: It is my professional opinion that (student’s name) should NOT be allowed to carry and self-administer any of his/her asthma medications while on school property or school related events.

Physician’s Signature: Date: I agree with the recommendations of my child’s physician and have informed my child that he/she may carry his/her asthma medications while on school property or at school-related events. Parent or Guardian’s Signature: Date:

Anne Frank Inspire Academy - Seizure ACTION PLAN Effective Date: (student’s name) is being treated for a seizure disorder. The information below is to help you if a seizure occurs during school hours.

Student:____________________________________ DOB:__________ School Year:

Grade:__________________ Advisory:___________________

Parent/Guardian: Home Phone: Cell: Treating Physician: Phone: Significant medical history: SEIZURE INFORMATION

Seizure Type Average Length Description

Average frequency: Seizure triggers or warning signs: Describe basic first aid procedures: Does the student need to leave the classroom after a seizure? _____ Yes _____No

EMERGENCY RESPONSE A “seizure emergency” for this student is defined as: Emergency Protocol

Call 911 Notify parent or emergency contact Notify doctor Administer emergency medications Medications are: Other

TREATMENT PROTOCOL DURING SCHOOL HOURS: Daily Medication Dosage & Time of Day Give Common Side Effects &

Special Instructions

EMERGENCY/RESCUE MEDICATION Does this student have a Vagus Nerve Stimulator (VNS)? _____Yes _____No

If YES, Describe magnet use: Special Considerations & Safety Precautions: (sports, trips, activities, etc.) Physician’s Signature: Date: Parent or Guardian’s Signature: Date: Basic Seizure First Aid:

• Stay calm & track time

• Keep child safe

• Do not restrain

• Do not put anything in mouth

• Turn child on side

• Stay with child until fully conscious

• Record seizure in log

• Expect to see pale/bluish discoloration of skin or lips

For tonic-clonic (grand mal) seizure: • Protect head

• Keep airway open/watch breathing

A Seizure is generally considered an Emergency, and you should CALL 911 when: • A seizure lasts longer than 5 minutes

• Student has repeated seizures without regaining consciousness

• Student has a first time seizure

• Student is injured or has diabetes

• Student has breathing difficulties

Anne Frank Inspire Academies Student Handbook We have read the Anne Frank Student Handbook, and we accept the procedures and policies contained within it. We have read and understand that failure to comply with the policies and procedures may result in disciplinary action, up to and including expulsion. Student Signature: Date: Parent / Guardian Name: Date: Parent Signature: Date: