WELCOME TO PAVE SCHOOLS!
NEW STUDENT
ENROLLMENT PACKET
STUDENT LAST NAME
STUDENT FIRST NAME
DOB
Complete the enclosed forms and submit the required documents:
Copy of Student Birth Certificate
Copy of Immunization Records
Parent/Legal Guardian Photo ID
Proof of Residence
Kindergarten Health Assessment Form (KHA)*
Must be completed and submitted to PAVE prior to the first day of school.
If student does not have a regular physician, contact Wake County Health
Department for an appointment at 919-250-3947
Also include the following, if applicable:
IEP/504
Copy of previous report card
** Este encuesta está disponible en español. **
PAVE SCHOOLS
CONFIDENTIAL RECORDS RELEASE
Authorization to release student information as per
the United States Code “Protection of the Rights and Privacy of Parents and Students.”
STUDENT LAST NAME
STUDENT FIRST NAME
DOB
Parent/Guardian:
The purpose of this form is for you to give permission for PAVE Schools to request your child’s
educational records from any previous school(s).
Registrar or Counselor:
You are hereby authorized to release from your records the following data concerning the student
listed below.
• Standardized test data
• Scholastic achievement data
• Medical data/immunizations
• Birth Certificate
• Social Security Number
• IEP Records
Student’s Previous School History
Grade
School Name
City
1.
2.
3.
4.
5.
I authorize the staff of PAVE Schools to request educational records for my student from any previous school(s).
Parent or Guardian Name
Signature
Date
PAVE SCHOOLS ENROLLMENT APPLICATION
NAMEOF
STUDENT:
LAST NAME
DATE OF
/
BIRTH:
FIRST NAME
GENDER:
/
Male
MIDDLE NAME
SOCIAL SECURITY
Female
-
NUMBER:
-
STUDENT
ADDRESS:
STREET ADDRESS (Apt #)
CITY, STATE ZIP
MAILING ADDRESS:
(IF DIFFERENT)
STREET ADDRESS (APT #)
CITY, STATE ZIP
With whom does the student reside (Choose only one):
Mother only
Father only
Both Parents
Legal Custodian
Parent/Guardian Contact 1
Other: _____________________________
Parent/Guardian Contact 2
Parent/Guardian Last Name
Parent/Guardian Last Name
Parent/Guardian First Name
Parent/Guardian First Name
Relationship to Student
Relationship to Student
([
])
Home Phone
([
])
Work Phone
([
])
Home Phone
([
])
Work Phone
([
])
Cell Phone
Email address
([
])
Cell Phone
Email Address
Address (include Apt. #)
Address (include Apt #)
City, State and Zip Code
City, State and Zip Code
Alternative Emergency Contact 1
Alternative Emergency Contact 2
Contact Last Name
Contact Last Name
Contact First Name
Contact First Name
Relationship to Student
Relationship to Student
([
])
Home Phone
([
])
Work Phone
([
])
Home Phone
([
])
Work Phone
([
])
Cell Phone
Email address
([
])
Cell Phone
Email Address
Address (include Apt. #)
Address (include Apt #)
City, State and Zip Code
City, State and Zip Code
Contact Restrictions
If there is (are) a person(s) who may NOT HAVE ACCESS to the child, please indicate below.
Name: __________________________________________________________________________
Relationship to student ___________________________________
Order of Protection
On File:
_____
_____
_____
_____
(If Yes, must obtain official court documents.)
Name: __________________________________________________________________________
Relationship to student ___________________________________
Order of Protection
On File:
Yes
Yes
No
No
(If Yes, must obtain official court documents.)
I will notify PAVE Academy Charter School in writing of any changes to the information on this card.
____________________________________________________________
Parent’s/Guardian’s Signature
__________________
Date
PAVE SCHOOLS
TRANSPORTATION REQUEST
PAVE Schools provides transportation service to students who reside in Raleigh, NC. Students in K-2 must have an adult at the stop to
pick them up. Please indicate below how this student will arrive at school in the AM and depart in the PM:
TRANSPORTATION (Check one for each)
AM:
Car
Bus
Walk
If BUS, please provide AM RALEIGH address:
_______________________________________________________________________________
PM:
Car
Bus
Walk
If BUS, please provide PM RALEIGH address:
______________________________________________________________________________
PM (early release):
Car
Bus
Walk
If BUS, please provide early release RALEIGH address:
______________________________________________________________________________
PAVE SCHOOLS
FIELD TRIP AUTHORIZATION
I permit my child to participate in field trips while they are enrolled at PAVE Schools.
I understand that the school will take all reasonable precautions to insure against the possibility of
accidents. However, I understand that this school or the adult in charge is not liable for accidents
occurring to children either on school premises or while on field trips as part of the school’s activities.
Information concerning a specific field trip such as date, time of departure, destination, cost, and
means of transportation will be sent to me by the teacher prior to each field trip.
Print Parent or Guardian Name
Signature
Date
PAVE SCHOOLS
MEDIA RELEASE
There may be times while my child is enrolled at a PAVE School when media or others wish to
photograph or videotape them.
I hereby grant permission to members of the local and national media (including newspapers, magazine,
television, and other media), PAVE Schools staff, and contracted employees to photograph and/or
interview my child.
I understand that this photograph/interview or portions thereof may be used for public view. I agree to
allow my child to participate in media projects without financial remuneration, and I understand that this
releases the photographer/interviewer from any future claims, as well as from any liability arising from
the use of said interview.
Print Parent or Guardian Name
Signature
Date
MCKINNEY-VENTO QUESTIONNAIRE
STUDENT LAST NAME
STUDENT FIRST NAME
DOB
Disclaimer: This questionnaire is intended to address the McKinney-Vento Act. Your child may be eligible for additional educational services through Title
I Part A, Title I Part C-Migrant, Individuals with Disabilities Education Act (IDEA) and/or Title X, Part C, Federal McKinney-Vento Assistance Act, 42
U.S.C.11435. Eligibility can be determined by completing this questionnaire. It is illegal to knowingly make false statements on this form. If eligible,
students are to be immediately enrolled in accordance with Bulletin 741, section 341.
1. !Yes !No
Is the student’s address a temporary living arrangement?
(Note: If you answered NO to this question, STOP. You have completed this form)
2. !Yes !No
Is the temporary living arrangement due to loss of housing or economic hardship?
3. Where is the student currently living? (Check all that apply)
! In an emergency/transitional shelter.
! Awaiting foster care placement
! Temporarily with another family because we cannot afford or find affordable housing..
! With an adult that is not a parent or legal guardian, or alone without an adult.
! In a vehicle of any kind, trailer park or campground without running water/electricity, abandoned
building or substandard housing.
! Emergency Housing
! In a hotel/motel.
! Other specific information:
________________________________________________________________________________
4. !Yes !No
Does your child have a disability or receive any special education
services? (Check One)
5. !Yes !No
Does your child exhibit any behaviors that may interfere with his or her
academic performance?
6 6. Would you like assistance with ! uniforms
! student records
! school supplies
! transportation
!
! Other? (Describe):
________________________________________________________________________
.________________________________________________________________________
7. !Yes !No
Does your child have siblings (brothers or sisters)?
8. The undersigned certifies that the information provided above is accurate:
___________________________________________________________________________________
Print Parent/Guardian Name/Adult Caring for Student Signature
Date
__________________________________________________________________________________
(Area Code)
Phone number
Street Address
City
State
Zip
PAVE SCHOOLS
RACE/ETHNICITY SURVEY
NAME OF STUDENT:
LAST NAME
FIRST NAME
DATE OF BIRTH
Place of Birth (City/State/Country):
_____________________________________________________________________________
If place of birth is outside of the United States, what was the date (month and year) of initial arrival into the United
States?
Month: ____________
Year: ____________
Is this student of Hispanic or Latino culture or origin? ! Yes ! No
elect one or more of the following rac
!
! African American/Black
! American Indian/Alaska Native
! Asian
! Native Hawaiian or Other Pacific Islander
! White
! I decline to state
HOME LANGUAGE SURVEY
Federal and state policies require schools to determine the language(s) spoken at home by each student. If the answer to
any of the questions below is a language other than English, your child may be assessed on the WIDA ACCESS Placement
Test (W-APT) to determine English language proficiency. Based on the results, your child may be identified as LEP and
qualify for ESL services. All identified LEP students will be assessed annually until exiting LEP identification.
1. Is a language other than English used in your home? !Yes !No
If NO, go to numbers 5 and 6.
If YES, what is that language? ________________________________
2. Is that language spoken in the home ! MORE OFTEN than English?
! LESS OFTEN than English?
3. What language is spoken by adults in the home?
_____________________________________
4. What was the first (1st) language your child learned to speak? ____________________________
5. Parent/Guardian Name___________________________________________________________
6. Parent/Guardian Signature: ______________________________________ Date: ___________
PAVE SCHOOLS
STUDENT NEEDS SURVEY
STUDENT LAST NAME
STUDENT FIRST NAME
DOB
Please provide as much information on your child so we can provide them with appropriate services. Your responses
have no impact on your child’s admittance into school.
SPECIAL EDUCATION/504/IEP
Yes
No
Don’t Know
My child has received special education services.
I would like for my child to be evaluated for Special Education
Services.
My child has an Individual Education Plan (IEP). If so, please
provide a copy of his/her IEP or list which school would have a
copy of his/her IEP form: ______________________________
My child receives services under 504 Rehabilitation Act.
My child has been evaluated for special education services. Date:
ADDITIONAL INFORMATION
My child has been retained? (If Yes, Grade)
My child has been suspended (If Yes, reason and # of times)
My child has been expelled (If Yes, when)
Additional comments:
Location:
Yes
No
Notes
PAVE SCHOOLS
General Health Information
1. List any heath concerns that you or your doctor have observed (asthma, stomach aches,
seizures, bed wetting, nightmares, etc):
2.
Does your child have any allergies?
Yes
No
If yes, please list:
______________________________________________________________________
______________________________________________________________________
3.
Was your child a full-term baby?
Yes
4.
Is your child presently on medication?
No
Yes
No
If yes, what medication and for what purpose?
______________________________________________________________________
______________________________________________________________________
5.
Has your child had any significant injuries, illness, or hospitalizations?
Yes
No
If yes, please explain:
______________________________________________________________________
______________________________________________________________________
6.
Has your child had any traumas or family stress (relocation, separation, divorce, death in
the family, etc)?
7.
Yes
No
Do you have any concerns about your child’s development (social, language, motor,
academic, etc)?
Yes
No