2012-2013 Student Enrollment Policy Packet Instructions & Fax Cover Sheet
PLEASE COMPLETE AND RETURN THE FOLLOWING ATTACHED DOCUMENTS
Student enrollment agreement
Student Service Intake Information form
Home Language Survey form
Request for Records sheet
Family Income form
FERPA Acknowledgement, Student Info & Photo Release
Social Security Number Form (incl. COPY of SS card)
* All REQUIRED signatures are denoted by an arrow
ADDITIONALLY, YOU MUST PROVIDE THE FOLLOWING
Copy of student’s state approved birth certificate
Copy of student’s Immunization Record
Most recent unofficial transcript or report card for student
Proof of residency
For minor student – current utility bill OR current mortgage/lease statement/agreement in
parent/legal guardian’s name matching address given on enrollment application
For adult student – current utility bill OR current mortgage/lease statement/agreement in
student’s name matching address given on enrollment application
Three ways to return your completed forms and documents
Scan and Email: [email protected]
Fax: 866-422-9027 (Complete the bottom portion and use this as your cover sheet/checklist)
Mail: Enrollment Service Center
Provost Academy
900 S. Gay Street, Ste 1000
Knoxville, TN 37902
STUDENT NAME:
DOB:
PHONE NUMBER (For Confirmation/Questions):
ga.provostacademy.com | Enrollment office 888-871-1133 | Enrollment fax 866-422-9027
© 2012 Provost Academy All Rights Reserved
Page 1|Rev 9/2012
Student Enrollment Agreement
I understand that I am enrolling (student name) _________________________________ in a school that operates in a
“virtual” environment.
Enrolling in this school means that your student will be attending a public school that has no physical classroom but still
must meet all requirements for public schools in Georgia. These requirements include but are not limited to: meeting
compulsory attendance requirements, participating in mandatory state standardized testing, communicating regularly and
professionally with school staff. I understand that while there is more flexibility than in a traditional school, students
are still expected to attend school five days a week for an average of 5-7 hours per class, per week. I understand
that participation in state standardized tests may require travel. Additional expectations are posted in the
Parent/Student Handbook.
I understand that students are expected to log in daily to the Provost Academy system. Students are considered truant
when the student has three (3) consecutive unlawful absences or a total of five (5) unlawful absences. Students will be
dropped from enrollment at Provost Academy when the number of unlawful days absent exceeds ten (10) consecutive days.
I understand that students and their parents or legal guardian(s) are subject to school-based truancy policies and practices.
I also understand that students are required to participate in all state and school standardized testing and to comply with the
terms of the Parent/Student Handbook.
State law provides that parents/legal guardians are responsible for ensuring that their student attends school. I understand
that students must complete assigned lessons, submit specified assignments to their teachers online, and complete
assessments. Students and/or their parents/legal guardians or designated representative are expected to participate in
regular telephone, e-mail, web conferencing, or if required, in-person contact with an academic advisor.
High school students are expected to perform their school work independently. While students may not need adult
supervision during the school day, they must still be in a safe and secure environment. I understand that by enrolling in an
online school, I will need to provide my child with a computer that meets the school’s minimum technical requirements as
well as reliable internet access. I understand that not having access to a working computer or internet does not excuse
absences.
Student Printed Name (REQUIRED)_____________________________________________________________________________________________
Student Signature (REQUIRED)_________________________________________________________________________________________________
Parent/Legal Guardian Printed Name (REQUIRED IF STUDENT IS A MINOR)____________________________________________________________
Parent/Legal Guardian Signature (REQUIRED IF STUDENT IS A MINOR)_______________________________________________________________
ga.provostacademy.com | Enrollment office 888-871-1133 | Enrollment fax 866-422-9027
© 2012 Provost Academy All Rights Reserved
Page 2|Rev 9/2012
Student Service Intake Information
Provost Academy is fully committed to providing quality education to all of our students, including those with special needs. We need
your help, so please complete this page with care.
STUDENT NAME:
DOB:
SECTION 1
Check Yes or No as applicable
Yes
No
Has your child ever been evaluated for special education?
If yes, what was the evaluation date and what school/facility conducted testing:
Does the student have a current IEP or 504 or does she/he currently qualify for one?
If yes, please complete section 2 of this form.
Does the student have an expired IEP or 504?
If yes, please provide evaluation and expiration dates:
Does your student take medication for any medical reason (ADHD, Diabetes, etc.)?
If yes, what medication?
What is the date of the student’s last hearing screening?
Does the student wear glasses?
What is the date of the student’s last vision screening?
Does the student use a hearing aid?
SECTION 2 – FILL OUT ONLY IF YOUR CHILD HAS A CURRENT IEP OR 504 PLAN
What type of plan does your student have?
IEP - Expiration Date: ________________
504 Plan – Expiration Date: ___________________
If your student has either of these, Provost Academy must receive a copy in order to process your enrollment
Diagnosis (check all that apply):
Learning Disability in
Reading
Math
Written Expression
Mental Retardation
Traumatic Brain Injury
Other Health Impairment
Emotional Disturbance/Behavior
Disorder
Speech/Language Impairment
Visual Impairment
Hearing Impairment
Orthopedic (Physical) Impairment
Child with a
Developmental Delay
Autism
Other:
ga.provostacademy.com | Enrollment office 888-871-1133 | Enrollment fax 866-422-9027
© 2012 Provost Academy All Rights Reserved
Page 3|Rev 9/2012
Home Language Survey
The Office of Civil Rights (OCR) and the Department of Education require that school districts and charter schools identify English
Language Learner (ELL) students in order to provide appropriate language instructional programs for them. Provost Academy has
selected the Home Language Survey as the method for determining if the student is a language-minority student.
STUDENT NAME:
DOB:
What is the student’s first language?
Does the student speak a language fluently other than English?
YES
NO
YES
NO
If yes, specify the language(s)
What language(s) is/are spoken in your home?
Has the student attended school in the United States in the past 3 years?
If yes, complete the following
Name of school
state
Years attended
Name of school
state
Years attended
Name of school
state
Years attended
Parent/Legal Guardian/Adult Student Signature (REQUIRED)_____________________________________________________________
Provost Academy has the responsibility under the federal law to serve students who are limited English proficient and need
English instructional services. Given this responsibility, Provost Academy has the right to ask for the information it needs to
identify English Language Learners (ELLs). As part of the responsibility to locate and identify ELLs, Provost Academy may
conduct screenings or ask for related information about students who are already enrolled in the school as well as from
students who enroll in the school in the future.
Provost Academy uses the ELDA as its screening tool. The school must administer the ELDA to a student during the
enrollment process so that a student’s enrollment status can be determined.
ga.provostacademy.com | Enrollment office 888-871-1133 | Enrollment fax 866-422-9027
© 2012 Provost Academy All Rights Reserved
Page 4|Rev 9/2012
Request For Records
Parent/Legal Guardian/Adult Student – Complete Top Portion Only
Provost Academy Georgia will use this form to request records from your students most recent school(s) attended. Please return this
form with your completed packet. You do not need to deliver this form to your student’s current/former school.
Student Name:
DOB:
Student’s Former School:
School Address:
School Phone Number:
Dates attended:
City:
School Phone Number:
State:
Zip:
School Fax Number:
Student’s Former School:
School Address:
Grade:
Dates attended:
City:
Grade:
State:
Zip:
School Fax Number:
Parent/Legal Guardian/Adult Student Signature (REQUIRED)_____________________________________________________________________
Attn: School Records Clerk
From: Provost Academy
The above named student has enrolled at Provost Academy for the 2012-2013 school year. Please provide the following records/documents:
Withdrawal documentation
2011-2012 Attendance Record
IEP documents
Official Transcript
Behavior Records
504 documents
Current progress report
Birth certificate
Health records
Immunization
Vision and Hearing Screening
Advanced Learning Plan
Please forward all Educational Records to:
Data Owner
Provost Academy Georgia
100 Edgewood Avenue, Suite 1220
Atlanta, GA 30303
Fax: 404-577-9023
Authorized Provost Academy Signature___________________________________________________________Date_____________________
ga.provostacademy.com | Enrollment office 888-871-1133 | Enrollment fax 866-422-9027
© 2012 Provost Academy All Rights Reserved
Page 5|Rev 9/2012
Family Income Form
In order to determine if Provost Academy will receive federal Title I funds for reading and/or mathematics or other services, certain
information is needed. Please complete this form and submit it with your enrollment documents. List only those students enrolling in
Provost Academy. This form will also be used to determine if the student may be eligible for use of a loaned laptop and/or
internet reimbursement. No determination of eligibility may be made until this form has been returned.
Student Information
Name
DOB
Gender
Grade
District of Residence
Indicate if child is a foster
child, ward of court, or food
stamp recipient*
*Please provide Food Stamp Case #
Calculating Household Income
In order to determine if In order to determine if Provost Academy will receive Title I funds, you will have to calculate the total amount of
income in your household. Include all income for all household members (including yourself, all children in the home, your spouse,
grandparents, and all others related and unrelated in your household). See lists below of the type of income to report.
Earnings from work: Wages / salaries / tips; Strike benefits; Unemployment compensation; Worker’s compensation; Net Income from self-owned business or farm
Pensions/Retirements/Social Security: Pensions; Supplemental Security Income; Retirement income; Social Security
Public Assistance/Child support/Alimony: Public assistance/Welfare Payments; Alimony/child support payments
Other Income: Disability benefits; Interest dividends; Estate/trusts/investments; Regular contributions from person(s) not living in household; Net
royalties/annuities/net rental income
Household Income
Total number of all household members, whether they receive income or not: ____________
Total of household members’ gross monthly income before taxes or anything else is taken out. Fill in one that is easiest for you to
calculate
$_______________________________
Annually
OR
$_________________________
Monthly
OR
$__________________________
Weekly
Certification and Signature
I certify that all of the above information is true and correct and that all income is reported. I understand this information is being given
for the receipt of federal funds and that school officials may verify the information on the form.
Parent/Legal Guardian/Adult Student Printed Name __________________________________________________________________________________________
Parent/Legal Guardian/Adult Student Signature _____________________________________________________________________________________________
ga.provostacademy.com | Enrollment office 888-871-1133 | Enrollment fax 866-422-9027
© 2012 Provost Academy All Rights Reserved
Page 6|Rev 9/2012
FERPA Acknowledgement and Student Information & Photo Release Form
The Family Education Rights and Privacy Act (FERPA) affords parents and students certain rights and responsibilities regarding the
student’s education records. Provost Academy’s FERPA policy can be found on the subsequent form and may be retained for your
records. Provost Academy and its designated curriculum provider, EdisonLearning, Inc., have found that to best serve the student’s
education needs, it is necessary to disclose a student’s name and address to the classes of vendors identified in the subsequent policy
document that provide important services related to your student’s education. In all cases, these vendors will have agreed to ensure
the confidentiality of the student’s name and address and not to use the information for purposes other than that contracted for the
student’s educational needs. Please review the policy and sign the below acknowledgement.
FERPA Acknowledgement (required for all students)
To best serve the student, Provost Academy requests the following consent to disclose the student’s name and address to the
specified class of contractors.
I hereby agree that my student’s name and address be provided to the above identified contractors to ensure that Provost Academy
can best meet my student’s education needs.
STUDENT NAME:
DOB:
Parent/Legal Guardian/Adult Student Signature (REQUIRED)_____________________________________________________________
Photo Release Opt Out (optional, complete only if wishing to opt out)
Provost Academy likes to celebrate our students and their successes and achievements. From time to time our school staff and
marketing departments may take photographs or videos at school activities and events and we ask for your permission to use any
images of your student for commercial and non-commercial purposes including print, digital/electronic, via the Internet and otherwise. If
this limited and defined use is acceptable, no other action is required. If it is not acceptable you have the right to deny such a request in
the area below.
I DO NOT release limited use of my student’s image and likeness for commercial and non-commercial use.
Student Signature_____________________________________________________________________________________________________________________
Parent/Legal Guardian Signature (IF STUDENT IS A MINOR)__________________________________________________________________________________
Date____________________________________________________
ga.provostacademy.com | Enrollment office 888-871-1133 | Enrollment fax 866-422-9027
© 2012 Provost Academy All Rights Reserved
Page 7|Rev 9/2012
Provost Academy FERPA Policy – For Your Records
Annual Notice of Rights under the Family Educational Rights and Privacy Act (FERPA)
Provost Academy protects the confidentiality of personally identifiable information regarding its eligible, thought to be eligible, and protected handicapped students (if
not protected by IDEA) in accordance with the Family Educational Rights and Privacy Act of 1974 (FERPA) and implementing regulations as well as IDEA and its
implementing regulations.
Education records are records that are directly related to the student, including computer media and videotape, which are maintained by an educational agency or by
a party acting for the agency. “Educational agency”, for purposes of this notice, means Provost Academy. For all students, the educational agency maintains
education records which include but are not limited to:
Personally identifiable information is confidential information that includes but is not limited to the students’ name, name of parents and other family members, the
address of the student or student’s family, and personal information or personal characteristics which would make the student’s identity easily traceable.
Directory information is information contained in an education record of a student which would not generally be considered harmful or an invasion of privacy if
disclosed. It includes but is not limited to, the student’s name, address, telephone number, electronic mail address, photograph, date and place of birth, major field of
study, grade level, enrollment status (e.g., undergraduate or graduate, full-time or part-time), participation in officially recognized activities and sports, weight and
height of members of athletic teams, dates of attendance, degrees, honors and awards received, and the most recent previous educational agency or institution
attended.
The Family Educational Rights and Privacy Act (FERPA) afford parents and students over 18 years of age (“eligible students”) certain rights with respect to the
student’s education records. They are: Parents have the right to inspect and review a child’s education record. Provost Academy will comply with a request to inspect
and review education records without unnecessary delay and before any meeting regarding and IEP or any due process hearing, but in no case more than 45 days
after the request has been made. Requests should be submitted in writing, indicating the records the parents wish to inspect, to the school principal or other
designated school official. Parents have the right to a response from the school to reasonable requests for explanations and interpretations of the records. Parents
have the right to request copies of the records. While Provost Academy cannot charge a fee to search for or to retrieve information, it may charge a copying fee as
long as it does not effectively prevent the parents from exercising their right to inspect and review the records. Parents have the right to appoint a representative to
inspect and review their child’s records. If any education record contains information on more than one child, parents have the right only to inspect and review the
information relating to their child.
If parents think information in an education record is inaccurate, misleading or violates the privacy or other rights of their child, they may request amendment of the
record. Requests should be in writing and clearly identify the part of the record they want changed, and specify why it is inaccurate or misleading. Provost Academy
will decide whether to amend the record and will notify the parents in writing of its decision. If Provost Academy refuses to amend a record, it will notify the parents of
their right to a hearing to challenge the disputed information. Additional information regarding the hearing procedures will be provided to the parents or eligible
student when notified of the right to a hearing.
Provost Academy will inform parents when personally identifiable information is no longer needed to provide educational services to a child. Such information must
be destroyed at the request of the parents. Parents have a right to receive a copy of the material to be destroyed. However, a permanent record of a student’s name,
address, and telephone number, his or her grades, attendance record, classes attended, grade level completed, and year completed may be maintained without the
limitation. “Destruction” of records means physical destruction or removal of personal identifiers from information so that the information is no longer personally
identifiable.
The school will provide, upon request, a listing of the types and locations of education records maintained, the school officials responsible for these records, and the
personnel authorized to see personally identifiable information. Such personnel receive training and instruction regarding confidentiality. The school keeps a record of
parties obtaining access to education records, including the name of the party, the date access was given, and the purpose for which the party is authorized to use
the records. Parents have the right to consent or refuse to consent to disclosure of personally identifiable information contained in the student’s education records,
except to the extent that FERPA authorizes disclosure without consent.
“Consent” means: the parent(s) have been fully informed regarding the activity requiring consent, in their native language or other mode of communication; they
understand and agree in writing to the activity; and they understand that consent is voluntary and maybe revoked at any time, information may be disclosed without
consent to school officials with legitimate educational interests. A school official is a person employed by the school, supervisor, instructor, or support staff member
(including health or medical staff and law enforcement unit personnel); state agency representative, person or company with whom the school has contracted to
perform a special task (such as an attorney, auditor, medical consultant, or therapist); or a parent or student serving on an official committee, such as a disciplinary or
grievance committee, or assisting another school official in performing his or her tasks. A school official has a legitimate educational interest if the official needs to
review an education record in order to fulfill his or her professional responsibility. Directory information may be released without parent consent. Parents have the
right to refuse to let an agency designate any or all of the above information as directory information.
Upon written request, Provost Academy discloses education records without consent to officials of another school district in which a student seeks or intends to
enroll. Parents have a right to file a complaint with the U.S. Department of Education concerning alleged failures by Provost Academy to comply with the
requirements of FERPA. Complaints may be filed with the Family Policy Compliance Office, U.S. Department of Education, 400 Maryland Avenue, S.W., Washington,
D.C. 20202-4605.
Provost Academy and its designated curriculum provider, EdisonLearning, Inc., have found that to best serve the student’s education needs, it is necessary to
disclose a student’s name and address to the following classes of vendors that provide important services related to your student’s education. In all cases, these
vendors will have agreed to ensure the confidentiality of the student’s name and address and not to use the information for purposes other than that contracted for
the student’s educational needs.
• Suppliers of computers and educational materials for purposes of shipping to/from the student’s home
• Customer care providers that handle overflow calls for Provost Academy
• Internet service provider
• Companies that enter the student information into a computer database for use by school officials
• Other contractors and subcontractors that Provost Academy or EdisonLearning, Inc. identifies as necessary to providing education service
ga.provostacademy.com | Enrollment office 888-871-1133 | Enrollment fax 866-422-9027
© 2012 Provost Academy All Rights Reserved
Page 8|Rev 9/2012
SOCIAL SECURITY NUMBER FORM
As a state approved charter high school, we must abide by Georgia Department of Education guidelines
and need to have either your student’s Social Security number and a copy of your SS card, OR a waiver
stating why you wish not to share it.
Student Name: ________________________________________________________
Last
First
--
Middle
--
Student’s Social Security Number
WE ALSO MUST HAVE A COPY OF YOUR SOCIAL SECURITY CARD
PLEASE ATTACH
Waiver
YOU MUST COMPLETE THE SECTION BELOW ONLY IF YOU DID NOT PROVIDE THE SSN ABOVE
This is to verify that I/my parent/guardian either do not have a social security number or do not wish to share it for the
following reason(s):
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
I verify that the statement made above is true and correct to the best of my knowledge, information and belief.
____________________________________
Signature of Parent/Guardian/Adult Student
________________
Date
__________________________________________________
Printed Name
ga.provostacademy.com | Enrollment office 888-871-1133 | Enrollment fax 866-422-9027
© 2012 Provost Academy All Rights Reserved
Page 9|Rev 9/2012