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2015-2016 School Year
Dear Parent or Guardian:Thank you for enrolling your child (ren) in César Chávez Academy. As a charter public school, we are pleased to offer you a free educational choice.
Enclosed you will find a registration package. Completing the enclosed package will confirm your child’s enrollment in César Chávez Academy.
This package contains very important documents, including permission forms, medication notification and emergency procedure information. Please read these forms carefully, complete them thoroughly and return this package to your academy.
We are pleased you have chosen our academy for your child and look forward to working with you and your student to achieve educational excellence.
Gabriela Jaime Thomas Goodley Adasina PhilyawSchool Leader-CCA-LE School Leader-CCA-UE School Leader-CCA-East
Kapeka VonKeltz Juan José MartinezSchool Leader-CCAMS School Leader-CCAHS
Javier Garibay RVP-CCA District
¡Si Se Puede!Mission:
To provide a safe atmosphere of academic excellence that promotes thinkers and problem solvers who work cooperatively and respectfully in an
inclusive environment.
Elementary (K-2)8126 W. Vernor Hwy.Detroit, MI 48209Ph. # 313.843.9440Fax # 313.297.6948G. Jaime, Leader
Elementary (3-5)4100 MartinDetroit, MI 48210Ph. # 313.361.1083Fax # 313.361.1095 T. Goodley, Leader
Elementary (K-5)4130 MaxwellDetroit, MI 48214Ph.# 313.924.0317Fax # 313.924.0425A. Philyaw, Leader
Middle School (6-8)6782 GoldsmithDetroit, MI 48209Ph. # 313.842.0006Fax # 313.842.0167 K. VonKeltz, Leader
High School (9-12)1761 WatermanDetroit, MI 48209Ph. # 313.551.0611Fax # 313.551.0552J. Martinez, Leader
Año escolar 2015-2016
Estimados Padres /Tutores:
Gracias por matricular a su niño(a) en al Academia César Chávez. Como una escuela publica ya establecida, nos da mucho gusto de ofrecerle una opción educacional gratis.
Incluido encontrara las formas necesarias para el registro. Completando estas formas confirmara la matricula de su niño(a) en la Academia César Chávez. Este paquete contiene documentos muy importantes; incluyendo la forma de permiso, notificación médica e información de procedimiento de emergencia. Favor de leer las formas con cuidado, completarlas y regresar el paquete a la academia.
Estamos complacidos que usted ha escogido a la Academia César Chávez para su niño(a) y esperamos trabajar con usted y su niño(a) para lograr una educación con excelencia.
Gabriela Jaime Thomas Goodley Adasina PhilyawDirectora -CCA-LE Director-CCA-UE Directora-CCA-East
Kapeka VonKeltz Juan José MartinezDirectora-CCAMS Director-CCAHS
Javier Garibay RVP-CCA Distrito
Elementary (K-2)8126 W. Vernor Hwy.Detroit, MI 48209Ph. # 313.843.9440Fax # 313.297.6948G. Jaime, Leader
Elementary (3-5)4100 MartinDetroit, MI 48210Ph. # 313.361.1083Fax # 313.361.1095 T. Goodley, Leader
Elementary (K-5)4130 MaxwellDetroit, MI 48214Ph.# 313.924.0317Fax # 313.924.0425A. Philyaw, Leader
Middle School (6-8)6782 GoldsmithDetroit, MI 48209Ph. # 313.842.0006Fax # 313.842.0167 K. VonKeltz, Leader
High School (9-12)1761 WatermanDetroit, MI 48209Ph. # 313.551.0611Fax # 313.551.0552J. Martinez, Leader
¡Si Se Puede!Mission:
To provide a safe atmosphere of academic excellence that promotes thinkers and problem solvers who work cooperatively and respectfully in an
inclusive environment.
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095 Fax 313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
STUDENT REGISTRATIONSTUDENT INFORMATIONLast name First name Middle name Home telephone
Address Apartment # City State ZIP Code
City of birth Grade Sex M or F (circle one) Birth date / / Social Security #
PREVIOUS SCHOOL INFORMATIONName of last school attended Dates attended / / - / / Telephone number
City State ZIP Code
School district in which parent or guardian lives
FAMILY INFORMATION Last name First name Employer English proficient Other language spoken and/or read Daytime phone Evening phoneFather Yes or No
Mother Yes or No
Step-parent Yes or No
Guardian Yes or No
Guardian Yes or No
Student lives with check one Information on other children in home
Parents Name of other children in home Birth date Social Security # GradeFather & stepmother
Mother & stepfather
Mother only
Father only
Guardians
Court-appointed guardians
Foster parents
Signature of Parent/Guardian Date Enrolled
FOR SCHOOL USE ONLY Date enrolled Date records requested Date records received Student ID # Homeroom teacher
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
Student ID # U.S. Citizen? Yes or No Copy of birth certificate? Yes or No Social Security card? Yes or No 2 forms of proofs of residency? Yes or No
MATRICULA de ESTUDIANTEINFORMACION DE ESTUDIANTE
Apellido Nombre Segundo Nombre Télefono Dirección Apartamento # Ciudad Estado Codigo Postal ______________
Ciudad de nacimiento Grado Sex o M or F (marque una ) Fecha de nacimiento / / Seguro Social #
Información de Escuela anterior Nombre de ultima escuela Fecha que asistió / / - / / Telefono de la escuela _________________
Ciudad Estado Codigo Distrito escolar donde viven los padres o tutotes
INFORMACION SOBRE LA FAMILIA Competente en
Apellido Nombre Empleador ingles Escribe y habla otro idoma Télefono de dia Télefono de nochePadre Si o No
Madre Si o No
Padre Si o No
Tutor Si o No
Tutor Si o No
Estudiante vive con:Marque una
Información de los otros miembros de la familia
Padres Nombres de estudiantes en la casa Fecha de nacimiento Seguro Social GradoPadre & MadrastraMare & PadrastroMadre solamentePadre solamenteTutoresTutores asignadosPadres Adoptivos
Firma de Padre/tutor Fecha
FOR SCHOOL USE ONLY Date enrolled Date records requested Date records received Student ID # Homeroom teacher
Student ID # U.S. Citizen? Yes or No Copy of birth certificate? Yes or No Social Security card? Yes or No 2 forms of proofs of residency? Yes or No
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209 313.843.9440313.361.1083 313.924.0317 313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
EMERGENCY PROCEDURE CARD 2015-2016Date of admission Date of release Grade
Child’s name (including last, first, middle initial) Child’s address (including house number and street, building/apartment number)
Child’s date of birth Home phone number( )
City State ZIP Code
Residency informationStudent lives with (please circle one) parents, mother, father, stepmother, stepfather, other (explain):Father’s/legal guardian’s name Mother’s/legal guardian’s name
Home address (if not child’s address) Home address (if not child’s address)
City State ZIP Code City State ZIP Code
Employer name Employer name
Employer address Employer address
City State ZIP Code City State ZIP Code
Employer phone number( )
Hours of employment a.m. to p.m.
Employer phone number( )
Hours of employment a.m. to p.m.
Contact instructionsPlease indicate whom we should contact in case of an emergency (other than parent):1st choice: Daytime phone: ( )
Alternate phone: ( )2nd choice: Daytime phone: ( )
Alternate phone: ( )Doctor: Office phone: ( )
Alternate phone: ( )Name(s) of person other than parent or legal guardian to whom child may be released:
Please indicate whom we should contact in case of an early dismissal (other than parent):1st choice: Daytime phone: ( )
Alternate phone: ( )2nd choice: Daytime phone: ( )
Alternate phone: ( )Are there any restrictions on your child’s activities at school? Yes or No If Yes, please explain.
Is there any medical information/concern you would like to share with the school which might help better serve your child? This information is confidential.
In case of separated or divorced parents, are there any legal restrictions on the release of child to either parent? If so, provide a copy of formal documentation to keep in your child’s file.
Emergency instructions I give permission to César Chávez Academy to secure emergency medical and/or surgical treatment for the above named minor child while in its care. I do not give permission to César Chávez Academy to secure emergency medical and/or surgical treatment for the above named minor child while in its care.Hospital preferred in case of emergency: Phone: ( )Health insurance policy name and number:Allergies:Signature of Parent or Guardian: Date
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
TARGETA DE EMERGENCIA 2015-2016Fecha de Admición Fecha de salida Grado
Nombre del estudiante (apellido, primer, inicial) Dirección (including house number and street, building/apartment number)
Fecha de nacimiento Telefóno de casa( )
Ciudad Estado Código Postal
InformacionEstudiante vive con: padres, madre, padre, madrastra, padrastro, otro (explicar):Nombre de padre/tutor Nombre de madre/tutor
Dirección (si no es dirección de su hijo(a) ) Dirección (si no es dirección de su hijo(a) )
Ciudad Estado Codigo Postal Ciudad Estado Codigo Postal
Nombre de Empleador Nombre de Empleador
Dirección Dirección
Ciudad Estado Codigo Postal Ciudad Estado Codigo Postal
Número de trabajo( )
Hora de empleo a.m. to p.m.
Número del trabajo( )
Horario de empleo a.m. to p.m.
InstruccionesFavor de indicar a quien podemos hablar en caso de emergencia. Las personas que usted indique támbien se les permitirá liberan a su hijo(a) :Primera opción: Telefóno: ( )
Celular: ( )Segunda opción: Telefóno: ( )
Celular: ( )Doctor: Telefóno de oficina: ( )
Otro numero: ( )Nombres de otros personas que puede levnatar a su hijo(a):
Favor de indicar a quien puede llamar para levantar su hijo(a) en caso de un despido temprano (alguien que ademas de padres/tutores):Primera opción: Telefóno de dia ( )
Telefóno: ( )Segunda opción: Telefóno de dia: ( )
Telefóno: ( )¿Hay alguna restriciones en las actividades de su hijo(a)? Si o No Si, por favor explicar.
¿Tienes alguna información medica/preocupación que le gustaria compartir con la escuela que la pueda ayudar?
En caso de una separación/divorcio, ¿ hay restricciónes en el despido de su hijo(a)? (Necesitamos una copia de documentos formales para el archivo de su hijo(a).)
Instrucciones de emergencia Doy permiso a la Academia Primaria César Chávez para asegura tratamiento medico o quirúrjico a mi hijo(a) en caso de emergencia. No, doy permiso a la Academia Primaria César Chávez para asegurar tratamiento medico o quirúrjico a mi hijo(a) en caso de emergencia.Hospital preferido en caso de emergencia: teléfono: ( )Numero de seguro medico y poliza:Alergias:Firma de los padre/tutor: fecha
NATIONAL SCHOOL LUNCH PROGRAM NOTIFICATION
César Chávez Academy participates in the National School Lunch Program (NSLP). The National School Lunch Program is a federally assisted meal program operating in public and nonprofit private schools and residential child care institutions. It provides nutritionally balanced, low-cost or free lunches to children each school day. The program was established under the National School Lunch Act, signed by President Harry Truman in 1946.
To find out if your student qualifies for free or reduced lunch rates for the 2015-2016 school year, please request the appropriate paperwork from César Chávez Academy office. Forms and guidelines will be available after July 1, 2015.
FOR SCHOOL USE ONLYDate of follow-up contact with parent to complete paperwork _______/_______/_______ (if registration packet completed before July 1, 2015)
Free and reduced lunch paperwork for the 2015-16 school year must be included with registration packets distributed after July 1, 2015. Do not use paperwork from the 2015-16 school year.
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax 313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader- M. TiltonSchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
NOTIFICACIÓN NACIONAL DEL PROGRAMA DEL ALMUERZO DE ESCUELA
La academia de César Chávez participa del programa nacional de almuerzo escolar (NSLP). El programa nacional del almuerzo escolar es un programa de comida federal que asiste a escuelas privadas, públicas y no lucrativas e instituciones residenciales de cuidado de niños. Proporciona almuerzos nutricionales y balanceados, baratos o gratis a los niños durante día de clase. El programa fue establecido bajo acto nacional del almuerzo de escuelas, firmado por presidente Harry Truman en 1946.
Para verificar si su estudiante califica para las tarifas gratis o reducidas del almuerzo para el año escolar 2015-2016, favor de solicitar una aplicación en la oficina de la academia de César Chávez. Las formas y direcciones para completarlas estarán disponibles después del 1 de Julio, 2015.
FOR SCHOOL USE ONLYDate of follow-up contact with parent to complete paperwork _______/_______/_______ (if registration packet completed before July 1, 2015)
Free and reduced lunch paperwork for the 2015-16 school year must be included with registration packets distributed after July 1, 2015. Do not use paperwork from the 2015-16 school year.
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax 313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
INSTRUCTIONAL PHILOSOPHY
IDEA 97 states that, to the maximum extent appropriate, children with disabilities should be educated with children who are not disabled. Special classes, separate schools or other removal of children with disabilities from the regular educational environment should occur only when the nature or severity of the disability of a child is such that education within regular classes with the use of supplementary aids and services cannot be achieved satisfactorily. César Chávez Academy embraces this philosophy, believing that special education students can best be educated in the regular classroom. Our teachers accept responsibility for all students in their classroom and modify, accommodate and adjust teaching techniques and classroom activities to meet the learning abilities of all children.
Please indicate on the Special Education Records Request form in this registration packet if your child has an Individual Education Plan in place. You will receive an invitation from the intervention specialist or resource teacher to attend an IEP meeting, if necessary, within the first month of your child’s enrollment at our academy.
The following signature indicates that I understand the instructional philosophy of the school.
Signature of Parent or Guardian Date
The academy is participating in an effort to identify, locate and evaluate all children who may have disabilities. For more information regarding assistance for students with disabilities or if you suspect a child may have a disability, please contact the school leader.
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax 313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
FILOSOFÍA
La IDEA 97 indica eso, al grado máximo apropiado, los niños con discapacidades deben ser educados con los niños que no son lisiados. Clases especiales, las escuelas separadas o el otro retiro de niños con discapacidades del ambiente educativo regular deben ocurrir solamente cuando la naturaleza o la severidad de la inhabilidad de un niño es tal que la educación dentro de clases regulares con el uso de ayudas suplementarias y de servicios no se puede alcanzar satisfactoriamente. La academia de César Chávez abraza esta filosofía, creyendo que los estudiantes de educación especial pueden ser educados lo mejor posible en la salon de clases regular. Nuestros profesores aceptan la responsabilidad de todos los estudiantes en su sala de clase y se modifican, acomodan y ajustan las técnicas y las actividades de enseñanza de la sala de clase para resolver las capacidades que aprenden de todos los niños.
Indique por favor en la forma de la solicitud de registro de educación especial en este paquete del registro si su niño tiene un plan individual de educación en lugar. Usted recibirá una invitación del especialista de la intervención o del profesor del recurso de asistir a una reunión de IEP, en caso de necesidad, dentro del primer mes de la inscripción de su niño en nuestra academia.
La firma siguiente indica que entiendo la filosofía educacional de la escuela.
Firma de padres/tutores Fecha
La academia está participando en un esfuerzo de identificar, localice y evalúe a todos los niños que puedan tener inhabilidades. Para más información con respecto a la ayuda para los estudiantes con inhabilidades o si usted sospecha un niño puede tener una inhabilidad, entre en contacto con por favor a líder de la escuela.
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax 313.924-0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
SPECIAL EDUCATION RECORDS REQUEST
□ My child has never received Special Education Services.
Signature of Parent or Guardian DatePlease complete this form for all new students who were enrolled in special education at their previous school. This request will then be forwarded to the special education department of your child’s previous school district.
Student name Grade Date of birth
Parent(s) name Phone number
Address City ZIP Code
Previous district attended Building
Address City ZIP Code
Disability
District contact person Phone
Date of last Individual Education Plan (please attach a copy)
□ Academic Records (Progress Report) □ Psychological Evaluation & Test Results □ I.E.P. □ M.E.T. Report□ Achievement Test Results □ Social Work Report□ Health History □ Evaluation Review□ Medical Report □ Other
Please sign below so that we may request your child’s special education records, including all evaluation reports, Multidisciplinary Team Reports and Individual Education Plans.
I grant permission for César Chávez Academy to receive the special education records of my
child from school district. (please print name) (please print name) Signature of Parent or Guardian Date
FOR SCHOOL USE ONLYDate form forwarded to special education teacher _______/_______/_______
Date records requested from previous school _______/_______/_______
Date records received from previous school _______/_______/_______
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948School Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
AUTORIZACION PARA EXPEDIENTES DE EDUCACIÓN ESPECIAL
□ Mi nino(a) nunca hay recivido educación especial
Firma de padre/tutor Fecha
Para estudiante de nuevo ingreso a la academia; que previamente recibía servicios de educación especial.Nombre del estudiante Grado Fecha de nacimiento:
Nombre de los padres/tutor Número de teléfono:
Dirección: Ciudad: Código Postal:
Distrito previo que asistió: Edificio:
Dirección:
Discapacidad:
Persona en contacto del distrito: Número de teléfono:
Fecha de último IEP (Favor de añadir una copia)
□ Academic Records (Progress Report) □ Psychological Evaluation & Test Results □ I.E.P. □ M.E.T. Report□ Achievement Test Results □ Social Work Report□ Health History □ Evaluation Review□ Medical Report □ Other
Padres,Favor de firmar abajo para solicitar el expediente de educación especial de su hijo (a).
Yo doy permiso a la academia César Chávez a que reciba el expediente de educación especial de mi hijo (a) _ (escriba su nombre)De distrito escolar. (escriba el nombre de la escuela anterior)
Firma de Padre/Tutor Fecha
FOR SCHOOL USE ONLYDate form forwarded to special education teacher _______/_______/_______
Date records requested from previous school _______/_______/_______
Date records received from previous school _______/_______/_______
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax 313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT (FERPA)
Please check the boxes of the items you would like to allow your child to participate in and sign below.
News information releaseThere may be times during the school year when the academy, The Leona Group, news media or others wish to photograph or videotape your child at César Chávez Academy for use in print, video, Internet or other communications methods.
I give my permission to César Chávez Academy to provide information concerning school activities with my child to the general news media. I also give my permission for my child’s name, portrait, picture or voice to be used for display or in promotional material in a variety of mediums for the academy or its management company, The Leona Group, L.L.C., and/or in local media coverage of academy events.
Communication releaseThere may be times during the school year when the academy, The Leona Group or others wish to identify your student by name and grade in newsletters, publications or yearbooks.
I give my permission to César Chávez Academy and its management company, The Leona Group, L.L.C., to identify my child by name and grade in newsletters, publications or yearbooks.
Artwork releaseThere may be times during the school year when the academy, The Leona Group, news media or others wish to use artwork created by your child at the academy for use in print, video, Internet or other communications methods.
I give my permission to César Chávez Academy to use artwork created by my child for promotional purposes in a variety of mediums for the academy or its management company, The Leona Group, L.L.C., and/or in local media coverage of academy events.
Student’s Name (please print)
Signature of Parent or Guardian Date
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax 313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
DERECHOS EDUCATIVOS FAMILIARES Y ACTO DE PRIVACIDAD (FERPA)
Favor de marcar los artículos que usted quisiera permitir a su hijo(a) participar y luego firme la forma.
Autorización para liberar la información de las noticiasPueden haber ocaciones durante el año escolar en que la academia, El grupo de Leona, los medios u otros medios de noticias desean tomar foto o grabar a su niño en la academia de César Chávez para el uso en la impresión, vídeo, Internet u otros métodos de las comunicaciones.
Doy mi permiso a la academia de César Chávez de proveer de la información referente a actividades de la escuela mi niño a los medios de noticias generales. También doy mi permiso para el nombre de mi niño, retrato, cuadro o voz que se utilizarán para la exhibición o en material promocional en una variedad de medios para la academia o su compañía de gerencia, El grupo de Leona, L.L.C., yo en la cobertura de medios local de los acontecimientos de la academia.
Autorización para liberar medios de comunicaciónPueden haber ocaciones durante el año escolar en que la academia, El grupo de Leona u otros deseen identificar su estudiante por nombre y grado en boletines de noticias, publicaciones o anuarios.
Doy mi permiso a la academia de César Chávez y a su compañía de gerencia, El grupo de Leona, L.L.C., para identificar mi niño por nombre y el grado en boletines de noticias, publicaciones o anuarios.
Autorización para liberar las ilustracionesPueden haber ocaciones durante el año escolar en que la academia, El grupo de Leona, medios u otros medios de noticias que deseen utilizar las ilustraciones creadas por su niño en la academia para el uso en la impresión, vídeo, Internet u otros métodos de las comunicaciones.
Doy mi permiso a la academia de César Chávez a las ilustraciones del uso creadas por mi niño para los propósitos promocionales en una variedad de medios para la academia o su compañía de gerencia, El grupo de Leona, L.L.C., yo en la cobertura de medios local de los acontecimientos de la academia.
Nombre de estudiante
Firma de padre/tutor Fecha
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax 313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
MEDICATION
Physicians may find it necessary to prescribe medication to be given during school hours. If your child is taking any medication it must be dropped off at the school office by the parent, who must make arrangements with the school to take this medication. Such medication must be in its original container and accompanied by the physician’s written instructions, containing the following information:
1. Student’s name2. Name of prescribing doctor3. Name of medication4. Instructions such as dosage and time to be given
Student’s name Birth date
Name of medication Diagnosis/purpose of medication
Form of medication Tablet/capsule Liquid Inhaler Injection Nebulizer Other
Dosage Frequency Time
How is medication to be administered?
Should the school be aware of any adverse reactions or precautions?
Home phone Emergency phone
Doctor’s name Doctor’s phone
The undersigned parent/guardian authorizes César Chávez Academy through its administrators and/or staff to administer medication or to supervise the taking of medication by my child.
It is understood that the undersigned parent/guardian shall immediately notify school personnel in writing in the event the prescription shall be discontinued or modified. Refills of the prescription shall be the responsibility of the parent/guardian.
Further, the undersigned shall release and indemnify César Chávez Academy and its employees from any liability or damage which may result from the administration of said medication as prescribed by the physician.
Signature of Parent or Guardian Date
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax 313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
MEDICAMENTOS
El medico puede encontrar necesario recetar medicina durante las horas escolares. Todo medicamento debe de estar en un envase con tapa resistente a niños y el nombre de la persona que toma la medicina.
1. Nombre del estudiante2. Nombre del doctor que resetó la medicina3. Nombre del medicamento4. Instrucciónes en cuando tomar el medicamento y la hora
Nombre del estudiante Fecha de nacimiento
Nombre de medicamento Diagnostico/propósito del medicamento
Forma de medicina Tableta/capsula Líquido Inhalador Injección Nebulizador Other
Dosis Frecuencia Hora
¿Como se debe dar el medicamento?
¿Debería de estar alerta la escuela de alguna reacción ó precaución?
El padre ó tutor asignado autoriza a la Academia Secundaria César Chávez y al personal para administrar el medicamento y supervisar al estudiante al tomar la medicamento.
Esta entendido que el padre ó tutor asignado debe de notificar al personal de la escuela inmediatamente descontinuado ó modificado. El padre ó tutor tiene la responsabilidad de re-llenar la receta.
Además, el asignado debe identificar a los empleados de la Academia Primaria César Chávez de algún daño ó que puede resultar de la administración de dicha medicina que a recetado el doctor.
Firma de padres/tutor Fecha
Número de teléfono
Número en caso de emergencia
Nombre del doctor
Numero de teléfono para doctor
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax 313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
IMMUNIZATIONState law prohibits a principal or teacher from admitting new entrants to school without a record of having received at least one dose of each: Measles, Mumps, Rubella, Polio, Diphtheria, Tetanus, Pertussis, Hepatitis B, and Chickenpox (Varicella). Children who have not received the required immunizations will be excluded from school until parents provide proof that all required immunizations have been received or until the school has a waiver on file.
Immunization scheduleImmunization Ages 4 – 6 Ages 7-18
Diphtheria, Tetanus and Pertussis
4 doses are required. If a dose was not given on or after the 4th birthday, a booster dose of DTP is required. Most children will have 5 doses.
4 doses are required.
Polio 3 doses are required. If the last dose was not given on or after 4th birthday, a booster dose is required. Most children will have 4 doses.
3 doses are required.
Measles, Mumps and Rubella
2 doses are required. The 1st dose must be given on or after the 1st birthday. The 2nd dose must be given at least 28 days from the 1st dose.
2 doses are required. The 1st dose must be given on or after the 1st birthday. The 2nd dose must be given at least 28 days from the 1st dose.
Hepatitis B 3 doses are required. Minimum of 28 days between 1st and 2nd doses; minimum of 56 days between 2nd and 3rd doses; minimum of 4 months between 1st and 3rd doses; and 3rd dose must be administered on or after 24 weeks or 168 days of age.
Varicella (Chickenpox)
1 dose required on or after 1st birthday. 1 dose required if received on or after the 1st birthday but prior to the 13th birthday OR 2 doses required, administered at least 28 days apart, if the child received the 1st dose on or after the 13th birthday.
Immunization waiverA parent or guardian wishing to exempt his/her child from a particular vaccination must provide a written statement indicating the religious or philosophical objections to the vaccination(s). A child who has been exempted from a vaccination is considered susceptible to the disease or diseases for which the vaccination offers protection. That child will be subject to exclusion from the school or program if an outbreak of a vaccine-preventable disease to which s/he is susceptible occurs.
By signing this waiver, you acknowledge that you are placing your child and others at risk of serious illness should s/he contract a disease that could have been prevented through proper vaccination.
I object to having my child immunized against the diseases I have checked below: Diphtheria Pertussis Measles Rubella Varicella (Chickenpox)
Tetanus Polio Mumps Hepatitis B Other _______________________
Reason:
Student’s Name (please print)
Signature of Parent or Guardian Date
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax 313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
VACUNASLa ley del estado prohíbe a un director o a profesor de admitir principiantes nuevos a la escuela sin un expediente de recibir por lo menos una dosis de cada uno: Sarampión, Paperas, Sarampión, Poliomielitis, Difteria, Tétanos, Pertussis, Hepatitis B, y varicela (varicela). Excluirán a los niños que no han recibido las inmunizaciones requeridas de escuela hasta que los padres proporcionan la prueba que se han recibido todas las inmunizaciones requeridas o hasta que la escuela tiene una renuncia en expediente.
Requisitos de VacunaciónVacunación Edades 4 – 6 Edades 7-18
Difteria, Tétanos y Pertussis
requieren 4 dosis. Si una dosis no fue dada en o después del 4to cumpleaños, una dosis de aumentador de presión del DTP se requiere. La mayoría de los niños tendrán 5 dosis.
se requieren 4 dosis
Poliorequieren 3 dosis. Si la dosis pasada no fue dada en o después del 4to cumpleaños, se requiere una dosis de aumentador de presión. La mayoría de los niños tendrán 4 dosis.
se requieren 3 dosis
Sarampión, Paperas y sarampión
requieren 2 dosis. La 1ra dosis se debe dar en o después del 1r cumpleaños. La 2da dosis se debe dar por lo menos 28 días de la 1ra dosis.
se requieren 2 dosis. La 1ra dosis se debe dar en o después del 1r cumpleaños. La 2da dosis se debe dar por lo menos 28 días de la 1ra dosis.
hepatitis femenino requieren 3 dosis. Mínimo de 28 días entre las 1ras y 2das dosis; mínimo de 56 días entre las 2das y 3ro dosis; mínimo de 4 meses entre las 1ras y 3ro dosis; y la 3ro dosis se debe administrar en o después de 24 semanas o de 168 días de la edad.
Varicela (Chickenpox) 1 dosis requerida en o después del 1er cumpleaños.
1 dosis requirió si está recibida en o después del 1r cumpleaños pero antes del décimotercero cumpleaños O de 2 dosis requeridas, administrado por lo menos 28 días aparte, si el niño recibió la 1ra dosis en o después del décimotercero cumpleaños.
Immunization waiverUn padre o un tutor que desea renunciar a las vacunas de su niño (a) debe proporcionar una declaración escrita que indica las objeciones religiosas o filosóficas a las vacunaciones. Consideran a un niño que se ha eximido de una vacunación susceptible a la enfermedad o a las enfermedades para las cuales la vacunación ofrece la protección. Ese niño estará conforme a la exclusión de la escuela o programará si un brote de una enfermedad evitable con la vacuna lo convierte susceptible.
Firmando esta renuncia, usted reconoce que usted está predisponiendo a su niño (a) a riesgo de enfermedades serias si sé contrae una enfermedad que se habría podido prevenir con la vacunación apropiada.
Yo, rehuso a que mi niño(a) reciba vacunas para prevenir las enfermedades que he marcado: Difteria Pertussis Sarampión Anti-sarampión Varicela (Chickenpox)
Tétanos Polio Paperas Hepatitis B Other _______________________
razón:
Nombre de estudiante (escriba su nombre)
Firma de padre/tutor Fecha
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax 313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
INTERNET ACCEPTABLE USE POLICY
Prior to receiving authorization to use the Internet, students and their parents/guardians must sign the following permission and contract document.
ParentsI give permission for my child to participate in the use of the Internet, a worldwide telecommunications network. I realize that (s)he will be able to access major networks throughout the world using the Internet. I understand that this access is designed and intended for educational purposes only. I also understand that the student will receive instruction in the appropriate use of this resource.
I realize the Internet contains material that is inappropriate for school purposes. I support the school’s position that students are responsible for not accessing such material. Such unacceptable use of the network will result in the suspension of all privileges. I will not hold César Chávez Academy accountable for unsuitable materials acquired by the student through Internet usage for school.
I acknowledge that I have read the Internet Acceptable Use Policy.
Student’s Name (please print)
Signature of Parent or Guardian Date
StudentsI will abide by the Internet Acceptable Use Policy. I understand that the Internet contains material inappropriate for school use and, therefore, will take personal responsibility not to access this material. I recognize that it is impossible for César Chávez Academy to prevent access to all controversial materials, and I will not hold them responsible for materials found or acquired on the network. I further understand that any violation of the regulations in this policy is unethical and may constitute a criminal offense. Should I commit any violation, my access privileges may be revoked and appropriate school discipline and/or legal action may be taken.
Student’s Name (please print) Grade
Student’s Signature Date
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax 313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
POLIZA PARA EL USO DEL INTERNET
Antes de recibir la autorización de utilizar el Internet, estudiantes y sus padres /tutor deberán firmar el siguiente documento y contrato de permiso
PadresDoy permiso para que mi niño(a) participe en el uso del Internet, una red mundial de telecomunicaciones. Entiendo que mi hijo(a) podrá tener acceso a redes importantes a través del mundo usando el Internet. Entiendo que este acceso está diseñado y proyectada solamente para propósitos educativos. También entiendo que el estudiante recibirá la instrucción para el uso apropiado de este recurso.
Comprendo que el Internet contiene material que es inadecuado para los propósitos de la escuela. Apoyo la posición de la escuela que los estudiantes sean responsables a no tener acceso a tal material. Tal uso de red será inaceptable y dará lugar a la suspensión de todos los privilegios. Yo no sostendré responsable a la academia César Chávez de materiales inadecuados adquiridos por el mi hijo(a) en el uso del Internet en la escuela.
Reconozco que he leído la póliza del Internet.
Nombre de estudiante (letra de molde)
Firma de padre/tutor Fecha
EstudiantesSeguiré la Póliza del Internet. Entiendo que el Internet contiene inadecuado material para el uso de la escuela y, por lo tanto, tomaré la responsabilidad personalmente de no tener acceso a este material. Reconozco que es imposible que la academia César Chávez prevenga el acceso a todos los materiales polémicos, y no los sostendré responsables de los materiales encontrados o adquiridos en la red. Entiendo que cualquier violación a las regulaciones de esta póliza es poco ética y puede constituir una ofensa criminal. Si cometo alguna violación, mis privilegios al acceso del Internet pueden ser revocados y disciplina apropiada por la escuela /y o acción legal puede ser tomada.
Nombre de estudiante Grado
Firma de padre/tutor Fecha
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax 313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
AFFIRMATION OF PRIOR DISCIPLINE RECORD
Check the appropriate box, provide all appropriate information and sign this document.
I affirm that the information provided here is true and that any false statement may result in forfeiting my child’s enrollment privileges at César Chávez Academy.
The undersigned affirms that has not been suspended or expelled from any school.
The undersigned affirms that has been suspended or expelled from a school.
If the student has been suspended or expelled, please provide the school name, date of suspension and/or expulsion, along with a detailed description of the incident(s).
Signature of Parent or Guardian Date
Signature of César Cávez Academy Staff Member Date copy sent for verification
Former school districtName and address of responding school district:
City State ZIP Code
( ) Phone number
Please check one: According to our records, we verify that the information provided above by the parent/student is correct.
According to our records, the information provided above by the parent/student is not correct. Appropriate documentation of suspensions and/or expulsions is attached.
Signature and title of sending district administrator Date
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax 313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
AFIRMACIÓN DEL EXPEDIENTE ANTERIOR DE DISCIPLINA
Marque la caja apropiada, proporcione toda la información necesaria y firme este documento.
Afirmo que la información proporcionada aquí es verídica y que cualquier declaración falsa puede dar lugar a perder los privilegios de la inscripción de mi niño en la academia de César Chávez.
Mi niño(a) no ha sido suspendido o expulsado de ninguna escuela.
Mi niño (a) ha sido suspendido o expulsado de la escuela.
Si su niño(a) ha sido suspendido o ha sido expulsado, favor de proporcionar el nombre de la escuela, fecha de la suspensión y/o expulsión, junto con una descripción detallada de los incidentes.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Firma de padre/tutor Fecha
Firma del Personal fecha de verificación enviada
Distrito Escolar PrevioNombre y dirección del distrito escolar:
Ciudad Estado Código Postal
( ) Número de Teléfono
Favor de marcar uno: Según nuestros expedientes, verificamos que la información proporcionada arriba por el padre del estudiante está correcta.
Según nuestros expedientes, la información proporcionada por el padre del estudiante no es correcta. Adjunto encontrara la documentación apropiada para suspensiones o expulsión las expulsiones.
Firma de un empleo de la escuela Fecha
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax 313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
HOME LANGUAGE SURVEY
Date Date of Birth Grade
Student name (last, first, middle initial) Address (including house number and street, building/apartment number)
Home #( )
Cell #( )
City State Zip Code
Parent/Guardian's name
1. What was the first language your child learned?
2. What languages, other than English, are spoken in the home?
3. What language is spoken most often by your child?
4. Was your child receiving help with English in their previous school?
Comments
Signature of Parent or Guardian Date
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax 313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
ENCUESTA de IDIOMAFecha Fecha de nacimiento Grado
Nombre del estudiante (apellido, primer, inicial) Dirección (including house number and street, building/apartment number)
Telefóno de casa( )
Cellular( )
Ciudad Estado Código Postal
Nombre de los padres
1. ¿Cual fue el primer lenguaje que su hijo(a) aprendió? 2. ¿Cual otros lenguaje además de ingles habla su hijo(a) en la casa?
3. ¿Cual es el lenguaje que su hijo(a) habla con mas frecuencia?
4. ¿Recibió su hijo(a) ayuda con ingles en su escuela previa?
Comentarios:
Firma de padre/tutor Fecha
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax 313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
ETHNICITY FORMDate Grade
Child’s name (including last, first, middle initial) Child’s date of birth
Home phone number( )
Cell number( )
Year of entry into the US
Race and Ethnicity: (Note: Both Part A and Part B of the question must be answered.)
Part A: Is this student Hispanic/Latino? (Choose only one)
o No, not Hispanic/Latino
o Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, Cuban, South or CentralAmerican, or other Spanish culture or origin, regardless of race.)
The above part of the question is about ethnicity, not race. No matter which box you selected above, please continue toanswer the following by marking one or more boxes to indicate what you consider your student’s race to be.
Part B: What is the student’s race? (Choose one or more)
o American Indian or Alaska Native (A person having origins in any of the original peoples ofNorth and South American, including Central America).
o Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or theIndian 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 originalpeople 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 NorthAfrica.)
NOTE: Both parts A and B MUST be completed. We encourage you to select an answer for both parts. If either part (A orB) is not answered, the U.S. Department of Education requires the school district to supply an answer on your behalf.
Person Completing this form (please print)___________________________________________________
Parent/Guardian Signature:_______________________________________ Date ___________________
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax 313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
FORMULARIO DE ORIGEN ETNICOFecha Grado
Nombre de estudiante (incluir apellido primer nombre e inicial)) Fecha de nacimiento
Numero de casa( )
celular( )
Año de entrada en los Estados Unidos
La raza y el origen étnico: (Nota: la Parte A e Parte B de la preguntas deben ser contestadas)
Parte A: El estudiante es hispano/latino? (por favor elija uno)
o No, no es hispano/latino
o Si, es hispano/latino ( Una persona Cubana, Mexicana, Puerto Riqueña, o del Sur o Centro América o cualquier otra cultura Hispana, independientemente de su raza)
La parte de arriba de la pregunta es sobre el origen étnico, no raza. No importa el cuadro que ha seleccionado anteriormente, por favor conteste lo siguiente, marcando una o mas cajas para indicar lo que usted considere es la raza de su hijo/a.
Parte B: Cual es la raza del estudiante? (elija uno o mas)
Indio Americano o Nativo de Alaska (Una persona con orígenes en cualquiera de los pueblos originarios deNorte y Sur América, incluyendo América Central). Asiático (Una persona con orígenes en cualquiera de los pueblos originales del Lejano Oriente, el sudeste de Asia, o elSubcontinente indio, incluyendo, por ejemplo, Camboya, China, India, Japón, Corea, Malasia,Pakistán, las Islas Filipinas, Tailandia y Vietnam.)
o Negro o Afro Americano ( Una persona que tiene sus orígenes en cualquier grupo racial negro de Africa)
o Nativo de Hawái u otra Isla del Pacifico (Una persona que tiene orígenes en cualquiera de los grupos originales de Hawái, Guam, Samoa, u otras Islas del Pacifico.
o Blanco ( Una persona que tiene orígenes en cualquiera de los grupos de personas originales de Europa, Medio este o Norte de África)
NOTA Las dos partes A y B DEBEN estar completas. Lo animamos a que elija una respuesta par alas DOS partes. Sea la Parte A o B . Si no responde, el Departamento de Educación requiere que el distrito escolar provea una respuesta en su nombre.
Persona completando la forma (por favor imprima):______________________________________________
Firma del padre/tutor:_______________________________________ Fecha___________________
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax 313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
STUDENT RESIDENCY
By completing this questionnaire, you help the school comply with the McKinney-Vento Act, Title X, Part C of the No Child Left Behind Act. Your truthful and accurate answers help the school identify services that the student may be eligible to receive.
Date Student Age Sexo Maleo Female
Grade
Student name (last, first, middle initial) Address (including house number and street, building/apartment number)
Home #( )
Cell #( )
City State Zip Code
Parent/Guardian's name
1. Where is the child living now? (check one box)□ In a shelter □ In a car□ In a motel or hotel □ In a trailer park or campsite□ With more than one family in a house or apartment□ With friends or family members other than parent or guardian□ None of the above
If you checked the box marked “None of the above” you do not have to complete the remainder of this form. Please sign below and return a copy of this form to the school office.
2. Does the living arrangement marked in Question 1 result from a loss of housing or economic hardship?□ Yes □ No □ Unsure
3. Who does the child live with?□ 1 parent □ 2 parents□ 1 parent and another adult□ a relative, friend(s) or other adult(s)□ alone with no adults□ an adult who is not the parent or legal guardian
Signature of Parent or Guardian Date
FOR SCHOOL USE ONLY□ Student not covered by McKinney-Vento Act□ Student covered by McKinney-Vento Act□ Follow-up required
Contact person at the student’s school who may know of the family situation:
Name Phone number
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax 313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
RESIDENCIA DE ESTUDIANTECompletando este cuestionario, usted ayuda a la escuela a llevar acabo el acto de McKinney-Vento, y el reglamento de “ningún niño se quede atrás. Su sinceridad y respuestas exactas a ayudara a la escuela a
identificar los servicios que el estudiante puede ser elegible a recibir.
Fecha Fecha de nacimiento Sexoo Hombreo Mujer
Grado
Nombre del estudiante (apellido, primer, inicial) Dirección (including house number and street, building/apartment number)
Telefóno de casa( )
Cellular( )
Ciudad Estado Código Postal
Nombre de los padres
1. ¿Donde vive el estudiante ahora? (Marque una)
□ en un refugio □ en un carro□ en un motel o hotel □ en un parque o sitio para acampar del acoplado□ Con más de un familiar en una casa o apartamento□ Con amigo(s) o familia que no son padres o tutor□ Ninguna de las antes mencionadas
Si usted marcó la caja “ninguno de las antes mencionadas” usted no tiene que terminar el resto de esta forma. Favor de firmar y regrese esta forma a la oficina de la escuela.
2. ¿Para los arreglos de vivienda que marco en la pregunta numero 1, fue por la perdida de su vivienda o por dificultad económica?
□ Si □ No □ No se
3. ¿Con quien vive el estudiante?□ 1 padre □ 2 padres□ 1 padre y otro adulto□ Familia, amigo(s) u otro adulto(s)□ Sin adultos□ Un adulto que no es un padre o tutor
Firma de padre/tutor__________________________________________________ Fecha____________________
FOR SCHOOL USE ONLY□ Student not covered by McKinney-Vento Act□ Student covered by McKinney-Vento Act□ Follow-up required
Contact person at the student’s school who may know of the family situation:
Name Phone number
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax 313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
FAMILY FEEDBACKDate / / (month) (day) (year)
Thank you for choosing César Chávez Academy. We are committed to serving our families in a pleasant and courteous manner. Please take a few minutes to complete this brief questionnaire. Your feedback is very important and your responses will be kept confidential.
How did you hear about César Chávez Academy? Newspaper ad Radio commercial Flier Saw building or sign Newspaper article Television commercial Postcard in mail Other: Web site Movie theater commercial Friend or relative ________________
Customer serviceIf you called for information, was the call answered promptly in a friendly and courteous manner? Yes No, please explain: _____________________________________________________________________________________
If you requested information via the school Web site, was your request answered promptly in a friendly and courteous manner? Yes No, please explain: _____________________________________________________________________________________
If you visited the school for information, were you greeted promptly in a friendly and courteous manner? Yes No, please explain: _____________________________________________________________________________________
Were all of your questions regarding César Chávez Academy answered to your satisfaction? Yes No, please explain: _____________________________________________________________________________________
In your wordsWhat words would you use to describe the school building and grounds? Clean Accessible Safe and secure Outdated, old Inviting School pride displayed Unclean Unorganized Modern Colorful Building, classrooms and office well-marked with signs
What words would you use to describe the school Web site? Easy to use Quality Appealing Not attractive Informative Up-to-date information Out-of-date information Difficult to use School pride shown Relevant information Confusing Too much information
What words would you use to describe school advertising you saw? Quality Interesting Not relevant Misleading Original Relevant Confusing Didn’t stand out Professional To the point Not representative of school, students or community
What words would you use to describe why you and your child chose César Chávez Academy? Quality education Safe, secure building Family-oriented Curriculum focus Caring staff Transportation Good reputation Diverse student body Small school atmosphere Uniforms Best option available No other choice Close to my home School leader Attention given to student and family needs
Other comments Please use this area to share any other comments you have.
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax 313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
OPINION FAMILIARFecha / / (Mes) (DIA) (año)
Gracias por elegir la academia de César Chávez. Nuestra misión es servir a nuestras familias de una manera cortes y agradable. Por favor tome unos minutos para completar este breve cuestionario. Su opinión es muy importante y sus respuestas se mantendrán confidenciales.
¿Cómo se entero de la academia de César Chávez? periódico Television tarjeta postal otro: sitio de red cine amigo o familia ________________ Radio folleto Billboard o anuncio
ServiciosSi usted llamó para información ¿Fue su llamada contestada puntualmente de manera amistosa y cortes? Si No, favor explicar: __________________________________________________________________________________
Si usted solicitó información vía la red de comunicación de la escuela, ¿Fue su petición contestada puntualmente de manera amistosa y cortes? Si No, favor explicar: __________________________________________________________________________________
Si usted visitó la escuela para información, ¿Le saludaron puntualmente de una manera amistosa y cortes? Si No, favor explicar: __________________________________________________________________________________
¿Todas las preguntas relacionadas con la academia César Chávez le fueron contestada a su satisfactoriamente? Si No, favor explicar: __________________________________________________________________________________
En sus palabras¿Qué palabras utilizarían usted para describir el edificio y el terreno de la escuela? limpio accesible seguridad anticuado, viejo Acogedor Respecto de la escuela sucio moderno lleno de colores
¿Qué palabras utilizarían usted para describir la página de red de la escuela? Facil de usar calidad atractivo atractivo informativo Informacion nuevo Informacion vieja Dificil para usar Respecto de la escuela Información pertinente confuso mucho informacion
¿Qué palabras utilizarían usted para describir el anuncio de la escuela? calidad Interesting No es pertinente engañoso Original pertinente confuso profesional específica
¿Qué palabras usted utilizarían describir el porqué usted y su niño eligió la academia César Chávez? Educacion con calidad seguridad Ambiente Familiar Empleados Amigables transporte Buen reputation Escuela pequena Uniformes Best option available Cerca de mi casa Director
Otros commentariosPor favor utilice esta área para compartir cualquier otro comentario que usted tenga.
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax 313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
CÉSAR CHÁVEZ ACADEMY PLEDGE
I, , parent of ,
support the mission and educational goals of César Chávez Academy
I resolve to show that I am an interested and responsible parent:
1. I will send my child to school every day ready to learn
2. I will send my child to school every day healthy, clean and well-cared for
3. I will teach my child to be well-behaved and show good manners
4. I will notified the school when my child is ill or is going to be absent
5. I will teach my child to respect all property and to take care of all school, supplies, books,
and equipment
6. I will attend conferences about my child
7. I will support the school and my child’s teacher in helping my child follow the code of
conduct
8. I will volunteer to work with my child’s teacher in school or at home
Student’s Name
Signature of Parent or Guardian Date
CCA ElementaryCCA-IntermediateCCA-ElementaryCCA-MiddleSchoolCCA-High SchoolVernor CampusMartin CampusEast CampusWaterman CampusWaterman CampusGrades K-2Grades 3-5Grades K-5Grades 6-8Grades 9-128126 Vernor Hwy.4100 Martin4130 Maxwell6782 Goldsmith1761 WatermanDetroit, MI 48209Detroit, MI 48210Detroit, MI 48214Detroit, MI 48209Detroit, MI 48209313.843.9440313.361.1083 313.924.0317313.842.0006313.551.0611Fax 313.297.6948Fax313.361.1095Fax 313.924.0425Fax313.842.0167Fax313.551.0552School Leader-G. JaimeSchool Leader-T. GoodleySchool Leader-A. PhilyawSchool Leader-K. VonKeltzSchool Leader-J. Martinez
PROMESA
Yo, _____________________________________, el padre de ______________________, sostengo la misión y las metas educativas de la Academia Primaria César Chávez.
Yo me comprometo a mostrar que soy un padre interesado y responsable:
1. Mandaré a mi niño(a) cada día a la escuela preparado para aprender.
2. Mandaré a mi niño(a) cada día a la escuela saludable, limpio y bien cuidado.
3. Enseñaré a mi niño(a) a ser educado y mostrar buenos modales.
4. Notificaré a la escuela cuando mi niño(a) este enfermo.
5. Enseñare a mi niño(a) a respetar toda propiedad y a cuidar todos los artículos escolares,
libros u equipo de la escuela.
6. Asistiré a las conferencias con respecto a mi niño(a).
7. Ayudare a la escuela y al maestro de mi niño(a) en ayudar a mi niño(a) a cumplir con el
código de conducta.
8. Me ofreceré a ser voluntaria(o) a trabajar con el maestro(a) de mi niño(a) en la escuela o
en la casa.
Nombre del Estudiante (letra de molde)
Firma del Padre o Tutor Fecha