Re-Enrollment - Ivy Academia

IVY ACADEMIA
BUSINESS OFFICE
K-12 ENTREPRENEURIAL CHARTER SCHOOL
7353 VALLEY CIRCLE BLVD
WEST HILLS, CA 91304
Educating Our Next Generation of Entrepreneurs
WWW.IVYACADEMIA.COM
TEL: (818) 716-0771 FAX: (818) 914-3674
Re-Enrollment Form for School Year
2015-2016
Please make sure to print clearly and provide the most accurate information
Form must be returned to teacher no later than February 27, 2015
STUDENT INFORMATION
Legal Name:
______________________________________________________
Last Name:
First Name:
Gender: □ Male □ Female
Grade Level:
_______________
2015 – 2016
Middle:
Date of Birth: ____/____/______
MM
DD
YYYY
Home Number:
(_____) _____-_______
Home Address: (complete only if address has changed in the last year)
_______________________________________________________________________________________________
Street Address
Apt./Unit
_______________________________________________________________________________________________
City
State
Zip Code
Student Lives with/Guardianship: (check all that apply)
□ Mother & Father
□ Mother
□ Both parents alternately
□ Father
□ Mother/Stepparent
□ Relative: ___________________
□ Father/Stepparent
□ Foster Home
□ Guardian
□ Other: _____________
PARENT INFORMATION/LEGAL GUARDIAN
Mother/Guardian Name: (complete only if information has changed in the last year)
______________________________________________________________________________________________
Last Name
First Name
Middle
Home Telephone Number:
Work Telephone Number:
Cell Telephone Number:
(_____) _____-_______
(_____) _____-_______
(_____) _____-_______
I would prefer to receive general school information on:
□ Cell number
□ Home number
□ Work number
E-mail Address: _________________________________________
Home Address: (if different than student)
______________________________________________________________________________________________
Street Address
Apt./Unit
______________________________________________________________________________________________
City
State
Zip Code
Father/Guardian Name: (complete only if information has changed in the last year)
______________________________________________________________________________________________
Last Name
First Name
Middle
Home Telephone Number:
(_____) _____-_______
Work Telephone Number:
Cell Telephone Number:
(_____) _____-_______
(_____) _____-_______
I would prefer to receive general school information on:
□ Cell number
□ Home number
□ Work number
E-mail Address: _________________________________________
Home Address: (if different than student)
______________________________________________________________________
Street Address
Apt./Unit
______________________________________________________________________________________________
City
State
Zip Code
IVY ACADEMIA
BUSINESS OFFICE
K-12 ENTREPRENEURIAL CHARTER SCHOOL
7353 VALLEY CIRCLE BLVD
WEST HILLS, CA 91304
Educating Our Next Generation of Entrepreneurs
WWW.IVYACADEMIA.COM
TEL: (818) 716-0771 FAX: (818) 914-3674
Stepparent Name:
______________________________________________________________________________________________
Last Name
First Name
Middle
Home Telephone Number:
Work Telephone Number:
(_____) _____-_______
Cell Telephone Number:
(_____) _____-_______
(_____) _____-_______
E-mail Address: _________________________________________
Ivy Academia Business Directory
Please complete if you would like your business to be included in our Parent Business Directory free of charge.
Type of Business:
_____________________________________________________________________
Name of Business:
_____________________________________________________________________
Brief Business Description:
_____________________________________________________________________
____________________________________________________________________
Contact Person:
____________________________________ Phone number: (_____) _____-_______
Business Address:
_____________________________________________________________________
Street Address
City
State
Zip
MEDIA RELEASE
I authorize: □ Ivy Academia □ Ivy Educational Foundation □ Ivy Parent Leadership Group (IPLG)
the right to use artwork, statements, interviews, photographs and audio/visual recordings of my child. This would be
for the purpose and/or use, in promotional, educational or fundraising materials including, but not limited to
videotapes, pamphlets, websites and brochures. I understand that the last names of the child and/or parent/legal
guardian will not be used in connections with said materials. I acknowledge that Ivy Academia shall have all
copyrights in and of such photographs and videotapes and may use such copyrights fully. I hereby release Ivy
Academia and its administration from all liability connected with the taking and use of said materials. In addition, I
waive all rights, interests or claims for payment in connection with any exhibition or release of said materials. I
acknowledge that this consent is voluntary and I acknowledge that I have legal authorization to sign this form on
behalf of this minor.
□ Yes, I authorize
□ No, I do not authorize
AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT
The undersigned, legal custodian of this student, a minor, hereby authorizes the principal or designee, into whose
care the aforementioned minor pupil has been entrusted, to consent to any X-ray examination, anesthetic, medical or
surgical diagnosis, treatment, and/or hospital care to be rendered to said minor upon the advice of any licensed
physician and/or dentist.
It is understood that this authorization is given in advance of any required diagnosis, treatment, or hospital care and
provides authority and power to the aforementioned agent(s) to give specific consent to any and all such diagnosis,
treatment, or hospital care which a licensed physician or dentist may deem necessary.
This authorization is given provisions of Section 25.8 of the California Civil Code, and shall remain effective for the full
school year unless revoked in writing and delivered to said agent(s). I understand that Ivy Academia, its officers and
its employees assume no liability of any nature in relation to the transportation of the said minor. I further understand
that all costs of paramedic transportation, hospitalization, and any examination, X-ray, or treatment provided in
relation to this authorization shall be borne by my undersigned.
□ Yes, I authorize
□ No, I do not authorize
SIGNATURE
I verify that the information contained in this document is true and correct to the best of my knowledge.
X _________________________________
Date: ____/____/______
Parent/Legal Guardian Signature
________________________________________________________________________________
Printed Name
Relationship to Student: (Check one)
□ Parent
□ Legal Guardian
□ Other (specify): ______________________________
TRACK
STEP 1:
ROOM #
ENTER STUDENT NAME AND PROVIDE ALL REQUESTED INFORMATION. PLEASE PRINT CLEARLY
Birth Date
LAST NAME
FIRST NAME
M M D D Y Y
SCHOOL NAME
Food Stamp, CalWORKS, KinGAP or
FDPIR Case #
Grade
HOUSEHOLDS WITH A FOSTER / INSTITUTIONALIZED (GROUP HOME) CHILD: COMPLETE SEPARATE APPLICATION FOR EACH FOSTER CHILD
IF the above is a FOSTER child living with your household, is the legal responsibility of a welfare agency or court.
write the FOSTER child's monthy personal use income.
.00 Write "0" if the child has no personal use income. Skip to STEP 4.
STEP 2:
ADD THE NAMES OF ALL OTHER CHILDREN IN HOUSEHOLD SCHOOL NAME
GRADE
FOOD STAMP, CALWORKS, KINGAP OR FDPIR CASE #
STEP 3:
LAST NAME
FIRST NAME
LAST NAME
FIRST NAME
LAST NAME
FIRST NAME
LAST NAME
FIRST NAME
LAST NAME
FIRST NAME
LAST NAME
FIRST NAME
LIST ALL ADULT HOUSEHOLD MEMBERS
Wellfare Payments,
Child Support /
Alimony
Earnings from Work Before Deductions
Job 1
Monthly
I cerfify that all of the information provided is true and
correct and that all income is reported. I understand
that this information is given in connection with the
receipt of Federal funds, that school officials may verify
the information on the application, and that diliberate
misrepresentation of the information may subject me
to prosecution under applicable State and Federal laws.
STEP 4:
LAST NAME
FIRST NAME
LAST NAME
FIRST NAME
LAST NAME
FIRST NAME
LAST NAME
FIRST NAME
ADULT HOUSEHOLD MEMBER MUST SIGN SIGNATURE HERE
PRINTED NAME OF ADULT HOUSEHOLD MEMBER:
Pay from Pensions, Retirement
or Social Security
Job 2 or Any Other
Income
Monthly
Monthly
Monthly
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
X
TODAYS DATE:
ADULT HOUSEHOLD MEMBER
SOCIAL SECURITY #
X
IF YOU DO NOT HAVE A SOCIAL SECURITY #, CHECK BOX
ADDRESS
CITY
ZIP CODE
FOR OFFICE USE ONLY
HOME PHONE
REVIEWER
WORK PHONE
DATE
MI
HS
F
T-45
R
NE
TRACK
SECCIÓN 1:
ROOM #
ESCRIBA EL NOMBRE DEL ESTUDIANTE Y TODA LA INFORMACION NECESSARIA. POR FAVOR ESCRIBA CLARO
Númbero de Identification del
estudiante
Fetcha de Nacimiento
APELLIDO
PRIMER NOBMRE
M M D D A A
NOMBRE DE ESCUELA
Grado
Estampillas de Comida, CalWORKS, KinGAP or
FDPIR Case #
Niños Adoptivos (Foster) o Instituionalizados: Complete una solicitud separada por cada niño adoptivo
Si un hijo(a) de CRIANZA reside en su hogar y es la responsabilidad legal de la Agencia del Welfare o la Corte,
escriba cuanto es el ingreso personal mensual de hijo(a) de CRIANZA.
.00 Escribe "0" si su hijo(a) no recibe dinero personal. Llene Sección 4.
SECCIÓN 2:
ANOTE TODOS LOS NIÑOS EN EL HOGAR
NOMBRE DE ESCUELA
GRADO
ESCRIBA EL NUMERO DE CASO: ESTAMPILLAS DE COMIDA, CALWORKS, KINGAP OR FDPIR CASE #
SECCIÓN 3:
APELLIDO
PRIMER NOMBRE
APELLIDO
PRIMER NOMBRE
APELLIDO
PRIMER NOMBRE
APELLIDO
PRIMER NOMBRE
APELLIDO
PRIMER NOMBRE
APELLIDO
PRIMER NOMBRE
ESCRIBE LOS NOMBRES DE TODOS LOS ADULTOS EN EL HOGAR
Certifico que toda la información proporcionada es
verdad y correcta y que todos los ingresos fueron
reportados. Entiendo que esta información se da con
respecto al recibo de fondos federales, y que los
oficiales de la escuela pueden verificar la información
en la aplicacion. Yo entiendo que si deliberadamente
proveo información falsa, mis niños podrian perder los
beneficios de comidas y yo podria ser procesado
legalmenta bajo las leyes estatales y federales
correspondientes.
SECCIÓN 4:
Escribe los nombres de todos los
adultos en el hogar
APELLIDO
PRIMER NOMBRE
APELLIDO
PRIMER NOMBRE
APELLIDO
PRIMER NOMBRE
APELLIDO
PRIMER NOMBRE
FIRMA DE ADULTO
ESCRIBE CON LETRA DE MOLDE SU NOMBRE
ADULTO):
Pensión, Retiro, o Segura Social
(Mensual)
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
Trabajo 1
X
(DE
Cualquier Otro
Ingreso Mensual o
Ingreso Mensual del
Trabajo 2
Ayuda Monetaria, Pensión
por Divorcia, Mentenimiento
de Hijos (Mensual)
Ingréso del Trabajo Mensual
(antes de las deducciones)
FECHA DE HOY
NUMER DE SEGURO SOCIAL DEL
ADULTO
X
MARQUÉ EN EL CUADRITO SI NO TIENE NUMBERO DE SEGURO SOCIAL
DOMICILLO
CIUDAD
CODIGO POSTAL
PARA USO OFICIAL SOLAMENTE
NUMERO DE TELEFONO DEL HOGAR
REVIEWER
NUMERO DE TELEFONO DEL EMPLEO
DATE
MI
HS
F
T-45
R
NE

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