2018-19 Enrollment Checklist - Trinity Charter Schools · Trinity Charter School – New Life 650 Scarbourough Canyon Lake, TX 78133 (830) 964-4390 *fax: (830) 964-4376 2018-19 Enrollment

Trinity Charter School – New Life

www.trinitycharterschools.org

650 Scarbourough Canyon Lake, TX 78133

(830) 964-4390 *fax: (830) 964-4376

2018-19 Enrollment Checklist

The following information is needed for each student at the time of enrollment. A student will not be permitted to

start school and will not be given a schedule of classes until the required Health-related documentation is

received. For students transferring from another Texas public school, a 30-day grace period is allowed. Please return

completed forms to the school office.

Information Required at Time of Enrollment:

Social Security Card (if no social security card, please communicate to Registrar at time of enrollment)

Birth Certificate

Immunization Record Immunizations must be up-to-date. Documentation must include month, day & year for each vaccine and a physician

signature or clinic stamp. Exemptions may be claimed for medical contraindications and reasons of conscience with the proper documentation. See

http://www.dshs.state.tx.us/immunize/school for further information.

Unofficial Copy of Transcript / or 8th

grade report card for incoming 9th

graders

Special Education/504 records if applicable

Face Sheet

Court Order/Adoption Papers

CPS Placement Agreement/LSS Placement Agreement

Student Rights/Educational Decision Maker Form

Psychological/Common Application

Forms to be Completed Prior to Enrollment:

TCS Enrollment Form

Home Language Survey

Support Services Checklist

Previous Schools Form

TB Skin Test Assessment

Certificate of Immunizations (may attach shot record in place of physician’s signature)

TCS Health Information

Allergy (Anaphylaxis) Emergency Action Plan (if necessary) Must be completed by a physician

for any child who has a severe allergy with risk of anaphylaxis. Severe allergies may include foods, insect bites

and stings, etc. Forms can be downloaded from the Trinity Charter School website. Medications required for

treatment should be brought to the school nurse prior to the first day of school.

Required Documents once School Year Has Begun:

Withdrawal forms and transcript/report card from previous school

FoF For Office Use Only

Date R Date Received

_____ ________________

D

TRINITY CHARTER SCHOOL ENROLLMENT FORM Start Date/SY: 18-19 ID:

The information on this form is pertinent to your child’s records. Please fill out as accurately as possible. The presentation of false documents or records

is an offense under Section 37.10 Penal Code. The enrollment of a child under false documents subjects the person to liability for tuition or costs under

Section 21.-31g of this code.

Student’s Legal Name: Grade:

(As listed on Birth Certificate) (Last) (First) (Middle) (Called By)

Sex: Date of Birth: / / Birthplace: Soc. Sec. #:

Student’s Home Address: Home Phone:

Mailing Address (if different):

Is Student Hispanic/Latino? (please circle): YES NO

{A person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture/origin, regardless of race}

Race/Ethnicity (please check all that apply): American Indian / Alaskan Native

Asian

Black / African

American Native Hawaiian / Other Pacific Islander

White / Caucasian

Name of Previous School: Name of Previous School: Last Grade Completed:

Address/City/State/Zip: Phone/Fax:

Legal Guardianship: Parent CPS JPD Other:

Yes No As a representative of the above agency, I wish to attend all student conferences, including 504 meeting,

attendance, discipline, ARDs, etc. as the legal educational representative of this student.

Has a Court Appointed Surrogate Parent Has an Educational Decision Maker* *A court appointed Educational Decision maker is required on cases after 9/2013

PRIMARY LEGAL GUARDIAN FAMILY INFO – who has legal custody regarding the education of the child

Last Name: First: Spouse’s Last Name: First:

Relationship to Child: Relationship to Child:

Address: Address:

Home Ph: Cell Ph: Home Ph: Cell Ph:

Work Ph: Fax #: Work Ph: Fax #:

Preferred Email: Preferred Email:

SECONDARY LEGAL GUARDIAN FAMILY INFO – joint custody and/or who also has educational rights to the child



Address: Address:




Parents: Have Educational Rights Rights Terminated



Address: Address:




Educational Decision Maker:

Last Name: First:

Relationship to Child: Court Appointed Educational Decision Maker Court Appointed Surrogate Parent

Address:

Home Ph: Cell Ph:

Work Ph: Fax #:

Preferred Email:

Court Volunteer/CASA/Guardian Ad Litem: Yes No Receives Educational Paper Work

Last Name: First:

Relationship to Child: Court Appointed Volunteer/CASA Guardian Ad Litem

Address:

Home Ph: Cell Ph:

Work Ph: Fax #:

Preferred Email:

Attorney Ad Litem/Attorney: Yes No Receives Educational Paper Work

Last Name: First:

Relationship to Child: Attorney Ad Litem Attorney

Address:

Home Ph: Cell Ph:

Work Ph: Fax #:

Preferred Email:

(Please

Siblings: (Names) Grade/Age TCS Campus, if applicable

I submit that the information given above is true and correct to the best of my knowledge.

Signature of Legal Parent/Guardian Date

Date

TRINITY CHARTER SCHOOL HOME LANGUAGE SURVEY

The information on this form is required by Section 39.023(m) of the Texas Education Code.

Grades K-12 Name of Child:

Nombre del Niño(a)

Campus: Campus: Trinity Charter School – New Life Campus Grade:

Escuela Escuela: Grado:

(1) What language is spoken in your home most of the time?

¿Qué idioma se habla en su hogar la mayoria del tiempo?

(2) What language does your child speak most of the time?

¿Qué idioma habla su niño(a) la mayoria del tiempo?

(3) What language do you (the parent/s) speak most of the time?

¿Oué idioma hablan más tiempo en su familia?

Signature of Parent / Guardian

Firma del Padre/Madre/ o Representante Legal

Date

Fecha

Student History Enrollment Form

(1) Where was your child born?

(2) Has your child ever lived outside the U.S. for two or more consecutive years? (two years in a row)

YES NO If YES, please complete the rest of this form.

If NO, you do not need to continue.

If YES -- Where?

If YES -- When your child lived outside the U.S., did he or she attend school regularly? (Check one:)

My child attended school regularly in all previous grades outside the U.S.

My child missed significant portions of one or more school years.

Please specify below, including years or partial years:

(3) If your child has ever been enrolled in a U.S. school, please answer below:

Where? Year(s) of Enrollment:

Entire School Year or Partial Year? Total Time Enrolled:

(4) Has your child ever participated in an ESL (English as a Second Language) or Bilingual Education Program? (Please

specify):

TEA 8/05

Trinity Charter School - New Student Health Information

Name Sex Grade Birthdate Teacher

In order to provide an optimum environment, it is important that we have an understanding of your child’s

health status. Contact the school nurse is you wish to discuss any health problems in more detail.

Condition Yes No Please explain “Yes” answers

Asthma

Blood Transfusions

Broken Bones

Diabetes

Head Injury

Heart Condition

Rheumatic Fever

Fainting Spells

Seizures

Surgery

Vision or Hearing Problems

Other:

Allergies: *If at risk for ANAPHYLAXIS, Allergy Emergency Action Plan is REQUIRED.

Medication

Food*

Environmental

Is he/she on medication?

Medication (Name & Strength) Dose/Frequency Days Taken Home School

*Is there any reason he/she can’t participate in a full program, including physical education activities?

Yes No If yes, please explain

*Have there been any stressful events in your child’s life that could have an impact on his emotional well being?

Example: death or serious illness in immediate family, major economic changes, abusive behavior, recent divorce or

remarriage?

Yes No If yes, please explain

*Has your child had chicken pox? Yes No If yes, when? (month/year)

*Has your child had any recent immunizations? Yes No If yes, please attach physician documentation.

Date Signature of Parent/Guardian

Please give name, address and phone number of the doctor who last examined your child.

Name: _________________________ Address: ________________________________Phone: ______________

TRINITY CHARTER SCHOOL SUPPORT SERVICES INFORMATION

We are requesting the following information from you in order to best meet the needs of your child. Thank you for your

assistance.

Child’s Name: Grade:

(Last) (First)

Has your child ever been retained in a grade level? No ____ Yes ____ Grade of retention: ____

NO, my child has not received any of the support services below at his/her former school.

YES, my child has received support services at his/her former school. If yes, please check the following

services/programs received:

PROGRAMS: Dates of Service:

ESL/BILINGUAL

SPECIAL EDUCATION (attach most recent ARD/IEP)

SECTION 504 (attach most recent 504 services plan)

READING/MATH EARLY INTERVENTION

OTHER (please describe)

Additional information/comments on services received:

Parent/Guardian Signature Date

Trinity Charter School Health Services Immunization Requirements

Attention Parent/Guardian of New Student:

We welcome you and your child to Trinity Charter School. To comply with Trinity Charter School board policy and

immunization requirements for the State of Texas, health information is requested/required when enrolling your child in school.

Please note the enrollment categories below and the attached forms for specific requirements/recommendations.

PPCD, PALS, KINDERGARTEN, AND 1ST GRADE STUDENTS ENTERING SCHOOL FOR THE FIRST TIME:

Students must submit completed immunization records before the start of school. Students will not be permitted to start

school and will not be placed in a class until the required immunization documentation is received.

IN STATE TRANSFERS:

Students are encouraged to present complete immunization records at the time of enrollment. If they are not available, a student

can be enrolled provisionally for no more than 30 days if he/she transfers from one Texas school to another, and is awaiting the

transfer of the immunization record from the previous school.

OUT OF STATE-OUT OF COUNTRY TRANSFERS:

Students must have complete immunization records to be enrolled and placed in a class. The student may be provisionally

enrolled if he/she has an immunization record that indicates the student has received at least one dose of each specified

age-appropriate vaccine required by the State of Texas that are current with the scheduled administration of the subsequent

doses in the series. To remain enrolled, the student must complete the required subsequent doses in each vaccine series on

schedule and as rapidly as is medically feasible and provide acceptable evidence of vaccination to the school nurse.

HOMELESS STUDENTS:

A student who is homeless, as defined by § 103 of the McKinney Act, 42 USC §11302, will be admitted temporarily for 30

days if acceptable evidence of a vaccination is not available. The school nurse will promptly refer the student to appropriate

public health programs to obtain the required vaccinations. He/she must begin and complete the vaccine series on schedule and

as rapidly as is medically feasible and provide acceptable evidence of vaccination to the school nurse.

Please return completed forms as soon as possible to the campus your child will be attending. If you have questions

regarding health requirements, or would like to discuss a health concern, please contact your campus nurse.

See Forms:

Enrollment Checklist

Certificate of Immunization Form or Clinic Immunization Record (required): Requires physician’s signature or stamp and

month/date/year for all immunizations;

TCS. Health Information Form: parent/guardian to complete form

Physician’s Report Form (strongly recommended)

CERTIFICATE OF IMMUNIZATION FOR 2018-19

Name: __________________________________ Male □ Female □ Date of Birth: _____________ Grade (2018-19): ________

Vaccine Date (MM/DD/YY) Requirements

Hepatitis B For students aged 11 - 15 years, 2 doses meet the requirement if adult hepatitis B vaccine

(Recombivax ) was received. Dosage (10 mcg/1.0 mL) and type of vaccine

(Recombivax ) must be clearly documented. If Recombivax was not the vaccine

received, a 3-dose series is required

Hepatitis B

Hepatitis B

Circle One: For K- 6th - 5 doses of diphtheria-tetanus-pertussis vaccine; 1 dose must have been received

on or after the 4th birthday. However, 4 doses meet the requirement if the 4th dose was

received on or after the 4th birthday.

Students 7 years and older: 3 doses of any combination DTP/DTaP/DT/Td vaccine

will meet the requirement id one does was received on or after the 4th birthday.

7th Grade: 1 dose of Tdap.Td is required if at least 5 years have passed since the last

Dose of tetanus-containing vaccine

8th-12th grade: 1 dose of Tdap is require when 10 years have passed since the last dose

of tetanus-containing vaccine. Td is acceptable in place of Tdap if a medical

contraindication of pertussis exists.

DTaP – DTP – DT - Td




DTaP

Hib For Drop-In Speech, PALS, Peer Model and PPCD: A complete Hib series is 2 doses plus

a booster dose on or after 12 months of age (3 doses total). If a child receives the first dose

at 12-14 months of age, only 1 additional dose is required (2 doses total). A child who

receives a single dose on or after 15 months of age is in compliance

Hib

Hib

Circle one: For Drop-In Speech, PALS, Peer Model and PPCD: For children 7-11 months: 2

doses. For children 12-23 months: if 3 doses were received prior to 12 months, then 4

doses are required, with a fourth dose on or after 12 months of age. If 1-2 doses were

received prior to 12 months, then 3 doses are required, with a 3rd dose on or after 12

months of age. If zero doses have been received, then 2 doses are required, with both

doses on or after 12 months of age. Children 24-59 months of age need at least 3 doses

with one dose on or after 12 months of age, or 2 doses with both doses on or after 12

months of age, or 1 dose on or after 24 months of age. Otherwise, one additional dose

is required.

PCV – PCV 7 – PCV13





Circle one: 4 doses* of polio vaccine, with one dose on or after the 4th birthday. However,

3doses meet the requirement if the 3rd dose was received on or after the 4th

birthday.

*If the 4 doses of polio include both OPV & IPV, then a booster dose at age 4

is not required; however, if the series is comprised of all IPV or all OPV, then

a booster dose at age 4 is required.

IPV - OPV

IPV - OPV

IPV - OPV

IPV - OPV

IPV - OPV

Circle one: The 1st does of MMR must be received on or after the 1st birthday. K-6th grade: 2 doses of MMR are required.

MMR – MMR/V

MMR – MMR/V

Vaircella The 1st dose of varicella must be received on or after the 1st birthday.

K-5th and 7th-12th grade: 2 doses are required Varicella

Had Chickenpox (MM/YY)

Meningococcal – MCV Students aged 11-12 years or enrolling in 7th – 12th grade: 1 dose is required

Hepatitis A The 1st dose of Hepatitis A must be received on or after 1st birthday.

K-5th grade: 2 doses 6 months are required Special note: a child will not be considered delinquent in this series until 18 months have elapsed

since receiving the 1st dose. Hepatitis A

Optional TB skin Test Decision made by health care provider. See TB assessment questions, attached.

______________________________________ ______________________________ ________________ Physician Signature/Stamp Required Physician Name (please print) Date

Trinity Charter School – TB Skin Test Assessment Questions

Name __________________ Birthdate __________ Grade ____

Does your child have a history of a Positive TB skin test?

YES NO I Don’t Know

If YES – you must provide evidence from a physician, clinic, or other acceptable source that they do not have

evidence of an active communicable disease.

Since your child’s last TB skin test:

Has anyone in your family had tuberculosis? YES NO I Don’t Know

Do you know of any situation where your child

was around an adult who has been diagnosed or

suspected as having TB?


Was your child born in or has your child visited a Foreign

country where there is a lot of TB?


If yes, which country/countries?

TB can cause fever of long duration, unexplained weight loss, weakness, chest pain, a bad cough, hoarseness, or

coughing up blood.

Has your child been around anyone, who has these problems? YES NO I Don’t Know

Has your child had any of these problems? YES NO I Don’t Know

To your knowledge, has your child had contact with anyone

who is at increased risk for TB infection? This includes

contact with anyone who is/has been an intravenous (IV)

drug user, HIV infected, in jail/prison, recently moved to the

US from a foreign country?


If the answer to any of these questions is “Yes”, you should seek the advice of your child’s physician regarding

the need for a TB skin test.

Previous Schools Attended

Please list all middle schools/high schools your child has attended prior to

enrolling in Trinity Charter School:

School name:

Address:

City, State, zip:

Phone number:

Fax number:

School name:

Address:

City, State, zip:

Phone number:

Fax number:

School name:

Address:

City, State, zip:

Phone number:

Fax Number:

2018-19 Family Survey/Encuesta de la Familia

Trinity Charter School New Life Campus

Jenny Peterson District Migrant Contact

Your child may be eligible for educational services through the Migrant Education Program. Contact the Office

of Migrant Education at 1-800-872-5327 if you need additional information.

1. During the last three years has your family moved from one school district to another?

Yes No

2. Do you or does anyone from your family do the following temporary or seasonal work?

Yes No

What type of work? Baling Hay Food Processing in Plants

Farming Picking Fruit or Vegetables Plant Nursery

Ranching Cotton Farming/Ginning Poultry Production

Fencing Combining/Harvesting Grain Clearing Land

Dairying Driving Tractors/Machinery Picking Nuts, Pecans, etc.

Fishing Tree Growing or Harvesting Other Similar Work

Su niño/a puede ser elegible para recibir servicios escolares proporcionado por el programa de Educación

Migrante. Entre el contacto con la Oficina de Educación Migrante si necesitas información adicional

1-800-872-5327.

1.¿Durante los últimos tres años ha viajado su familia de un distrito escolar a otro?

Sí No

2.¿Trabaja usted o alguien en su familia en una de las siguiente actividades temporalmente?

Sí No

¿Qué tipo de trabajo? Juntando paja Cultivando arboles

Cultivando Cosecha de frutas/verduras En viveros

En Ranchos/granjas Cultivando algodon En producción de aves

Cercando Mexclando/cosechando granos Limpiando terrenos

En lecherias Manejando tractors/maquinaria Recogiendo nueces, etc.

Pescano Procesando comida en fabricas Otro trabajo similar

Student Name/Estudiante Birthdate/Fecha de Nacimiento Grade/Grado

Parent Name/Padre Telephone/ Teléfono

ESL LPAC FORM

Student Name _ Grade ID Number _____________ Campus New Life LPAC Meeting Date ___________________

Home Language (Check one or fill in other) English 98 Spanish 01 Other

Entry Date __________________ Exit Date _______________ Exit Reason _____________________

LPAC Facilitator Signature: _______________________________

Signature of Registrar: ____________________________________ Date entered into TxEIS:_________________

Due to Registrar within 10 days of LPAC meeting. Maintain form in cumulative folder Developed 070814

Years in US School (Circle one)

0 - First enrolled in U.S. schools in the second semester of the current school year. 4 - Has been enrolled in U.S. schools for all or part of four school years.

1 - First enrolled in U.S. schools in the first semester of the current school year. 5 - Has been enrolled in U.S. schools for all or part of five school years.

2 - Has been enrolled in U.S. schools for all or part of two school years. 6 - Has been enrolled in U.S. schools for all or part of six or more school years.

3 - Has been enrolled in U.S. schools for all or part of three school years.

Bilingual (Circle one) Note: If the student is in an ESL program, leave the Bilingual field blank.

0 - Does not participate in Bilingual Program. 4 - Dual Language Immersion/Two Way.

2 - Transitional Bilingual/Early Exit. 5 - Dual Language Immersion/One Way.

3 - Transitional Bilingual/Late Exit.

ESL (Circle one) 0 - Does not participate in ESL Program. 2 - ESL Content Based. 3 - ESL Pull Out.

LEP Code (Circle one) 0 - Not LEP 1 – LEP

F - Exited from LEP - Monitored 1 (M1) - The student has met the exit criteria for the bilingual/ESL program, is no longer classified as LEP in PEIMS, is in his first year of monitoring, and is not eligible for funding due to the fact that he is not LEP.

S - Exited from LEP - Monitored 2 (M2) - The student has met the exit criteria for the bilingual/ESL program, is no longer classified as LEP in PEIMS, is in his second

year of monitoring, and is not eligible for funding due to the fact that he is not LEP.

Parental Permission Code (Circle One)

3 - Parent/Guardian requested BIL. (non-LEP student) 7 - Parent/Guardian did not respond. 8 - Parent/Guardian was not contacted.

A - Parent/Guardian denied BIL; approved ESL. B - Parent/Guardian approved ESL – Not deny BIL. (PK-8) C - Parent/Guardian denied placement in language program.

D - Parent/Guardian approved BIL placement. E - Parent/Guardian approved BIL not avail. appr. ESL. F - Parent/Guardian approved LPAC

plan. (9-12)

G - Parent/Guardian approved BIL/ESL. H - Requested Placement of non-LEP student in ESL. J - Approved ESL alternative

(non-LEP student) language program.