University of Texas-University Charter Schoolparc.memorialhermann.org/uploadedFiles/_Library_Files/PARC/UT...University of Texas-University Charter School ... Fecha de PRIMER ingreso

University of Texas-University Charter School

2200 E. 6th

St. | Austin, Texas 78702 | (512)232-6403 phone | (512)232-9177 fax

Welcome to University of Texas-University Charter School at Memorial Hermann! Attached is

the enrollment packet for your student. This packet must be completed and given to school

personnel before your child can attend school.

Students cannot be dual enrolled. If your child is enrolled in another school you

must withdrawal them prior to enrolling your student at Memorial Hermann.

A copy of the following must be included with your child’s enrollment packet:

Birth Certificate

Up-to-date Immunization Record (see attached form)

Copies of the following items are not required for enrollment but are helpful with

course determination and additional educational services:

Proof of withdrawal and grades from last school attended

Transcript, if applicable

IEP (Individual Education Plan), if student receives special education services

If you have any questions regarding enrollment please call Jackie Swanier, Campus Registrar

@ 713-558-3984.

JLO 08/15 Revised Student Enrollment Form

University of Texas-University Charter School-Enrollment Form, Pg 1

2200 E. 6th


ENROLLMENT OPTION:

Signature required on page 1 (Enrollment Option) and Page 2 (False Information Statement)

I have been informed of the option of enrolling the student in the local public school district. I

understand University of Texas- University Charter School is an educational option. The UT-UCS

Student Guidelines for 2016-2017 are available on the district website: http://ut-ucs.org/

Signature of Guardian with educational decision making rights:

Signature: _______________________________________________ Date: ___________________

STUDENT INFORMATION: (Please Print Clearly and use Black/Blue Ink only)

UT-UCS Campus Name: Grade Level:

Last Name: Gender:

Male Female

First Name: Middle Name: Date of Birth:

Social Security #: 1st Date of Instruction:

Student's Ethnicity: Hispanic/Latino Student’s Not Hispanic/Latino

Student’s Race: American Indian/Alaskan Native Asian Black/African-American

Native Hawaiian/Other Pacific Islander White

Has student attended UT-UCS before? Y N If Yes, name of campus

:

PREVIOUS SCHOOLS ATTENDED: (starting with most recent school)

School Name1: Phone Number:

School Address1: (City State, Zip) Phone Number:

School Name2: (If applicable) Phone Number:

School Address2: (City State, Zip) Phone Number:

Is another school district funding this student’s residential placement? Y N

If Yes, name of district? (include city/state)

GUARDIAN INFORMATION: Last Name: First Name:

Relationship To Student: Date Of Birth:

Cell Phone: Work Phone: Home Phone:

Email Address:

Does Guardian reside outside local school district where

facility lies? Y N Do you have educational decision making rights for the

student? Y N If No, attach Court Order.

Physical Address Mailing Address: Same

Street:

City, State, Zip:

Memorial Hermann

1

Student’s Last Name: First Name: Date of Birth:

OTHER INDIVIDUALS ASSISTING/REPRESENTING STUDENT’S INTEREST

Is student assisted by or represented by any of the following agencies or individuals?

Yes No Custodial Guardian living at different address: Send Educational Information

Name:

Address:

Phone: Email:

Yes No Court appointed surrogate or guardian: Send Educational Information

Name:

Address:

Phone: Email:

Yes No Attorney ad litem: Send Educational Information

Name:

Address:

Phone: Email:

Yes No Probation Officer: Send Educational Information

Name:

Address:

Phone: Email:

Yes No Supporting agency such as CASA, MHMR, DARS… Send Educational Information

Name:

Address:

Phone: Email:

MEDICAL INFORMATION:

Had Varicella (Chicken pox)? Y N Date: Medical Conditions/Food Allergies:

MEDICAL /EMERGENCY INFO:

Family Physician Name: Physician’s Phone: Hospital of Choice:

Other Contacts: Daytime Phone: Relationship To Student:

Medical Authorization- By signing you are authorizing, in absence of listed persons, school officials to render such treatment as

may be deemed necessary in an emergency for the health of the student.

Signature:

Date:

FALSE INFORMATION STATEMENT: Signature required on page 1 (Enrollment Option) and Page 2 (False Information Statement)

I certify I am the parent, guardian or person having lawful control of the student named on the enrollment form. I further certify

this student, in my charge, meet all other qualifications for enrollment and have not knowingly falsified any information provided

on this enrollment form.

Full Name (Signature): Relationship:

Jlo 8-7-15 Revised Student Enrollment Form, Page 2

University of Texas-University Charter School-Enrollment Form, Pg 2

2200 E. 6th


2

University of Texas-University Charter School 2200 E. 6

th St. Austin, Texas 78702 (512)232-6403 phone (512)232-9177 fax

HOME LANGUAGE SURVEY

This form is to be completed for all students new to UT- UCS, all grade levels.

STUDENTS’ NAME: _____________________________________________________ Nomber del estudiante Last/Apellido First/Nombre M.I./Segundo Nombre

DATE OF BIRTH: ______________________________________ Fecha de Nacimiento Month/Mes Day/Dia Year/Ano

______________________________________________________________ _______________________________

Campus/Escuela Grade/Grado

HOME LANGUAGE SURVEY/Informacion sobre el idioma que se habla en casa

1. What language is spoken in your home most of the time? ______________________________________

Cual el idioma que mas habla en su hogar? Language/Idioma

2. What language does the student speak most of the time? ______________________________________

Caul es la idioma que habla el estudiante? Language/Idioma

If a language other than English is marked in question 1 or 2 above, please complete the questions below.

Sihan indicado idioma aparte de ingles, favor de completer las preguntas que siguen.

3. Student’s country of Birth/Pais Natal:______________________________________________________

4. Is the student a citizen of the U. S. A.?

Es el estudiante ciudadano de los Estados Unidos de American? Yes/Si No/No

5. Date of FIRST ENTRY into ANY SCHOOL in the U.S.A._____________________________________

Fecha de PRIMER ingreso en CUALQUIER escuela en los Month/Mes Year/Ano

Estados Unidos de America.

Signature of Parent/Guardian:___________________________________________Date:_______________

Firma de Padre/Guardian:

Revised June 2016

Memorial Hermann

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2200 E. 6th


STUDENT MILITARY AND FOSTER CARE QUESTIONNAIRE

Campus: _______________________ Students Name: ___________________________________Grade: ____________________ Due to House Bill 525 and Senate Bill 833, it has become necessary for the University of Texas University Charter School to collect the status of students in regards to military and foster care. This information must be reported to the Texas Education Agency in our District PEIMS submissions. Please mark one box in each section and return this form to your campus as soon as possible. Military – Is your student a dependent of an active military member? Please check one box below.

0 - My Student is not a military connected student 1 - US Military - Army, Navy, Air Force, Marine Corps or Coast Guard on active duty 2 - Texas National Guard on active duty 3 - Reserve Force of the US Military on active duty

****************************************************************** Foster Care – Is your student receiving Foster Care Services? Please check one below.

0 - My student does not receive Foster Care Services. 1 – Student is currently receiving Foster Care Services. If applies, please provide a copy of the Texas DFPS Placement Authorization Form (Form 2085), DFPS Kinship Caregiver Agreement or a court order that designates the student is in the conservatorship of the Department of Family and Perfective Services.

Parent/Guardian Signature Date

Memorial Hermann

4

University of Texas-University Charter School 2200 E. 6

th St. | Austin, Texas 78702 | (512)232-6403 phone | (512)232-9177 fax

Family Survey 2016-2017

Campus: Date:

Student Name: Date of Birth: Grade Level:

Dear Parents, In order to better serve your children, our school district is helping the State of Texas identify students who may qualify to receive additional educational services. Please answer the following questions and return this form to your child’s school. The information provided below will be kept confidential.

1. Within the past 3 years have you, or your child, moved from one school district, city or state to another? YES or NO

2. If yes, did you, or your child, move so you could work or look for work in agriculture or fishing?

NO (STOP here and return survey to your child’s school.) YES (Please check all that apply below)

Working in a cannery

Working on a dairy farm or ranch.

Working in a fishery

Working on a poultry farm

Working in a plant nursery,

orchard, tree growing or harvesting

Working in a slaughterhouse

Other similar work, please explain: ______________________________________________________

Please complete the following information: (Please print) Best time to contact you: _____________

Parent/Guardian Name: Home Address/Apt Name: City: Zip Code:

Telephone Number: Mailing Address: City: Zip Code:

Fruit, vegetables, sunflower, cotton, wheat,

grain, on farms or ranches, fields & vineyards

For School Use Only: Please send survey with two YES responses to [email protected]

2nd Attempt: 3rd Attempt:

Memorial Hermann

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2200 E. 6th



STUDENT RESIDENCY QUESTIONNAIRE

2016-2017

This form helps determine the services the student may be able to receive under the McKinney-Vento Act (42 U.S.C.11435). The answers to this residency form help determine the services the student may be eligible to receive. Please answer fully and honestly to assist school staff in appropriately enrolling your child.

Student Name: School:______________________________________

Is your current address a temporary living arrangement, due to loss of housing or economic hardship? Yes No

If you answered “YES” to the above question, please complete the section below, sign, and return this form. If you answered “No,” please skip the

section below, sign, and return this form.

The student lives: in a shelter in a motel/hotel in a car or RV at a campsite in transitional housing temporarily with another family in a house, mobile home, or apartment (how long? ) at another location

The student lives: with one or both parents with a legal guardian with friend(s) with an adult who is not the student’s legal guardian alone with no adult(s)

I am: the parent of the above-named student the legal guardian of the above-named student an adult who is not a legal guardian to the above-named student a student living separate and apart

Name of Parent(s)/Legal Guardian: _________________________________________________________________________________________

Previous Address: ______________________________________________________________________________________________________ Street Address City State Zip

Last School Attended when Permanently Housed: School Year: ____________________________

Presenting a false record or falsifying records is an offense under Section 37.10, Penal Code and enrollment of a child under false documents subjects the person to liability for tuition or others costs. TEC Sec.25.001(h) Education.

I have read and understood the information provided above. I understand that if any of the responses given on this form are found to be false, I will be subject to criminal, civil and administrative penalties. I declare under penalty of perjury under the laws of this state that the information provided here is true and correct and of my own personal knowledge.

Signature Print Name Date

Rev: 6/23/2016

Memorial Hermann

6

Confidential

Information


Form for Compensatory Education Funding Qualification

School Year 2016–2017

Confidential

Information

Please fill out one form for each child attending school, sign each form, and return it to UT-University Charter School. Instructions for filling out the form are attached included in the parent information packet. If you need help, please call Audrea Carmack (P) 512-232-6403.

1. Child’s name:

(Last Name) (First Name) (Middle Initial) Child’s grade: School: SSN:_

(Optional)

2. Is the child a foster child? If this is a foster child, check here [ ] and list the child’s monthly personal use income:

$ . SKIP sections #3 and #4 and GO TO section #5.

3. Are you receiving food stamps or TANF benefits for your child? If you are receiving food stamps or TANF benefits for this child, check

here [ ], list the case number, and then SKIP section #4 and GO TO section #5.

Food stamp case number:_ TANF case number:_

4. All other households. Complete this section if the child is not a foster child and you are not receiving food stamps or TANF benefits for the

child (you did not complete sections #2 or #3). (If you have more than one child attending school and you are completing a separate form for

each, you may complete this section only once.)

List all household members including the child listed above. Show all income. Then GO TO section #5.

NAMES CURRENT MONTHLY INCOME

Name of household members

(include the child listed above)

Check if $0

income

Monthly earnings (before

deductions) Job #1

Monthly welfare, child

support, alimony

Monthly payments from

pensions, retirement,

social security

Monthly earnings from job #2 or any other monthly

income 1. $ $ $ $ 2. $ $ $ $ 3. $ $ $ $ 4. $ $ $ $ 5. $ $ $ $ 6. $ $ $ $ 7. $ $ $ $ 8. $ $ $ $ 9. $ $ $ $ 10 $ $ $ $

5. Signature and social security number. I certify that all of the above information is true and correct and that the food stamp or TANF case number is current and correct or that all income is reported. I understand that this information is being given in order for the school to receive

additional state funding and that school officials may verify the information.

Signature of adult_ Social security number - -

Printed name_ Home phone_ Work phone_

Mailing address City_ State_ TX__ Zip Date

6. Consent for release of information to Texas Education Agency for program audit purposes. I consent to the release of

the above information by the UT-University Charter school to the Texas Education Agency for the purposes of auditing

compensatory education funding reports. I understand that the Texas Education Agency will not share the information with any

other entity or program. I also understand that the failure to sign this consent does not affect my child’s eligibility for free or

reduced price meals or free milk.

Signature of adult Date

FOR OFFICIAL USE ONLY: Food Stamp or TANF Eligible [ ]

Total Monthly Income $ Household Size Income Eligible [ ]

Determining Official Signature Date

Retain in District – Do Not Send to TEA SF – 141

SF-141R08

Memorial Hermann

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2200 E. 6th


Student and Parent Agreement for Acceptable Use of the District’s Electronic Communications System

(Please reference the Acceptable Use Guidelines and Acceptable Use Policy)

Parent: 2016-2017 School Year

I have read the Acceptable Use Guidelines (AUG) and Acceptable Use Policy (AUP) regarding the District's Electronic Communications System. In consideration for the privilege of my child using the District's Electronic Communications System, and in consideration for having access to the public networks, I hereby release the District, its operators, and any institutions with which they are affiliated from any and all claims and damages of any nature arising from my child's use of, or inability to use the system, including, without limitation, the type of damage identified in the District's policies and administrative regulation.

I give permission for my child to participate in the District's Electronic Communications System, utilizing District-provided equipment and resources, and certify that the information contained on this form is correct.

If permission is given, the student must complete the following Student section.

I do not give permission for my child to participate in the District's Electronic Communications System.

If permission is not given, your child will not be able to use networked District computers, online services and resources, or other computer-related equipment at school.

Student:

I understand that my computer use is not private and that the District will monitor my activity on any computer system while at school.

I have read the Acceptable Use Guidelines (AUG) and Acceptable Use Policy (AUP) regarding the District's Electronic Communications System and agree to abide by their provisions. I understand that violation of these provisions may result in suspension or revocation of system access and/or other appropriate disciplinary or legal action in accordance with the Student Code of Conduct and applicable laws.

Student’s Name (Please Print) UT-UCS Campus

Student’s Signature Date Parent/Guardian Signature Date

Revised 6/23/16

8

Rev: 6/23/2016

2200 E. 6th



PARENT/GUARDIAN STATEMENT OF STUDENT SERVICES

2016-2017

Student Name: School:______________________________________

1. Was your child receiving bilingual or ESL services at their previous school? Yes No

2. Was your child receiving 504 services at their previous school? Yes No

3. Has your child ever been serviced in special education? Yes No

If you answered “YES” to the above question, please complete sections 4-8 below, sign, and return the form. If you answered “No,” please skip to

section 8 below, sign, and return the form.

If your child has received special education services at a prior school, please completing the remainder of the form to help us start your student’s services as soon as possible.

4. Name and address of last school student received special educational services:

_______________________________________________ _________________________________________________________________ School Name School Address 5. Students qualifying disability: ___________________________________________________________________ (LD, ED, OI, ID, Etc.) 6. Services Received at Previous School: (Check all that apply)

7. My child received special education services in the past but was dismissed per IEP or ARD committee. Yes No

If yes, please provide the year your student was dismissed _____________.

8. I certify the information provided is true and correct.

__________________________________________ ____________________________________________ _____________________

Sign Name Print Name Date

Speech Self-Contained Auditory Services Counseling Services Occupational Therapy

Psychological Services Physical Therapy Recreational Therapy Visual Impairment

Other: _______________________________

Memorial Hermann

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University of Texas-University Charter Schoolparc.memorialhermann.org/uploadedFiles/_Library_Files/PARC/UT...University of Texas-University Charter School ... Fecha de PRIMER ingreso

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