Legacy Academy Enrollment Form

Legacy Academy
ENROLLMENT APPLICATION
Student Name (as it appears on birth certificate)
Student Date of Birth

Month Day Year
Date
State of Birth
City of Birth
Check one

Kindergarten Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8
Proof of Age documentation provided (must be legible): Birth Certificate, Passport, Other
Other
Student Preferred Name
Student Gender
Parent/Guardian First and Last Name
Relationship to Student
Parent/Guardian First and Last Name
Relationship to Student
Parent/Guardian please provide a current, state issued, photo identification. If someone other then mother is listed here, please provide proof of custody paperwork (date and time stamped by the court)
Email Address
example@example.com
Phone Number
Work Number
Parent/Guardian Address
Parent/Guardian City
Parent/Guardian State
Parent/Guardian Zip Code
County: (Parent/Guardian will be responsible to provide the school with the proof of residency at time of enrollment, any time an enrolled student changes their residency or at the request of the school. Once student is enrolled a parent/guardian must provide the school with proof of residency annually
County
Proof of Address provided
Deed, mortgage, lease, current home owners or renters insurance declaration page, current real property tax bill, utility bill, receipt of utility installation, bank statement, paycheck or pay stub issued to the parent, notification from Social Security and/or Jobs and Family Services, Notarized affirmation from parents of current resident address. (must be current or dated within 30 days of enrollment)

Yes No
Is the student's address the same as the parent/guardian address above?

If not, list the student address below:
Mailing Address
Mailing State
Mailing Zip Code
2112 Mock Road, Columbus, Ohio 43219
Legacy Academy
ENROLLMENT APPLICATION
Is your child Hispanic or Latino?

Yes No
What ethnicity is your child?

American Indian or Alaskan Native Asian Black or African America Native Hawaiian or Other Pacific Islander White
What is the primary language used in the home regardless of the language spoken by the student?

What is the language most often spoken by the student? What is the language the student first acquired?

How long has your son/daughter attended school in the United States?
Years
Months
When did you first enroll your son/daughter in school in the United States?
Year
Grade
First Emergency Contact
Phone Number
Second Emergency Contact
Phone Number
Physician Name
Phone Number
Hospital Preference
Medical Concerns
Does your child take any medications frequently or daily

Yes No
If yes, what medications are taken daily?
Has your child been diagnosed with allergies by a doctor?

Yes No
If yes, please list the allergies here
Does the student have any food allergies?

Yes No
If yes, please specify
Who has authorization to pick up the student from school? Please provide the full name of each individual:

*NOTE: Any person picking up students will be required to show state issued picture identification.

2112 Mock Road, Columbus, Ohio 43219
Legacy Academy
ENROLLMENT APPLICATION
PREVIOUS SCHOOL
Please provide information regarding the most recent school(s) the student attended.
SCHOOL #1
School Name
Start Date

Month Day Year
Date
End Date

Month Day Year
Date
Reason For Leaving
Address
City
State
Zip Code
Phone
Fax
SCHOOL #2
School Name
Start Date

Month Day Year
Date
End Date

Month Day Year
Date
Reason For Leaving
Address
City
State
Zip Code
Phone
Fax
SCHOOL #3
School Name
Start Date

Month Day Year
Date
End Date

Month Day Year
Date
Reason For Leaving
Address
City
State
Zip Code
Phone
Fax
2112 Mock Road, Columbus, Ohio 43219
Legacy Academy
ENROLLMENT APPLICATION
SPECIAL SERVICES IEP
In order to continue to provide appropriate services, does your child receive Special Education Services?

Yes No
SPECIAL SERVICES 504
Will the student need 504 services at our school?

Yes No
MCKINNEY-VENTO
Does the student lack a fixed, regular, or adequate nighttime residence?

Yes No
- Fixed-stationary, permanent, and not subject to change - Regular-used on a regular (i.e. nightly) basis - Adequate-sufficient for meeting both the physical and psychological needs typically met in home environments. The purpose of this form is to identify and support students who may be eligible to receive services under the McKinney-Vento Homeless Act 42 U.S.C. 11435. The eligibility information on this form is confidential and should be reviewed and re-evaluated every school year. More information can be found at: https://www2.ed.gov/policy/elsec/leg/esea02/pg116.html

*Eligibility is determined on a case-by-case basis. Please contact the school counselor with any questions or concerns regarding the rights of home- less students including immediate enrollment, school selection, transportation, or participation in school programs.
MIGRANT WORKER
Did your family make a move within the past 36 months so that a parent/guardian could work as a migratory agricultural worker, migratory fisher or to join a spouse who is a migratory agricultural worker, migratory fisher?
Do you have a certificate of eligibility for the student from the Ohio Migrant Education Center (OMEC)?

Yes No Yes No Legible copy of the certificate of eligibility was provided to the enrollment office.
The school will not exceed the capacity of the School's programs, classes, grade levels, or facilities. When the number of applicants for admission exceeds the School's capacity, admissions will be determined by a lottery of applicants. Preference shall be given to students attending the school the previous year, to students who reside in the district in which the school is located, and to siblings of students attending the school the previous year.

2112 Mock Road, Columbus, Ohio 43219
Legacy Academy
IMMUNIZATIONS
DTAP/DT TDAP/TD DIPHTHERIA, TETANUS, PERTUSSIS
Kindergarten Four (4) or more doses of DTaP or DT, or any combination. If all four doses were given before the 4th birthday, a fifth (5) dose is required. If the fourth dose was administered at least six months after the third dose, and on or after the 4th birthday, a fifth (5) dose is not required.

Four (4) or more doses of DTaP or DT, or any combination. Three doses of Td or a combination of Td and Tdap is the minimum acceptable for children age seven (7) and up. One (1) dose of Tdap vaccine must be administered prior to entry.
1st
2nd
3rd
4th
5th
6th
1st
DTAP Booster
POLIO
Three (3) or more doses of IPV. The FINAL dose must be administered on or after the 4 th birthday regardless of the number of previous doses. If a combination of OPV and IPV was received, four (4) doses of either vaccine are required. *** Three (3) or more doses of IPV or OPV. If the third dose of either series was received prior to the fourth birthday, a fourth (4) dose is required; If a combination of OPV and IPV was received, four (4) doses of either vaccine are required.
1st
2nd
3rd
4th
MMR MEASLES, MUMPS, RUBELLA
Two (2) doses of MMR. Dose one (1) must be administered on or after the first birthday. The second dose must be administered at least 28 days after dose one (1
1st
2nd
Date

Month Day Year
Date
Results

Positive Negative
1st
2nd
1st
2nd
2112 Mock Road, Columbus, Ohio 43219
Legacy Academy
IMMUNIZATIONS
HEP B HEPATITIS B
Three (3) doses of Hepatitis B. The second dose must be administered at least 28 days after the first dose. The third dose must be given at least 16 weeks after the first dose and at least 8 weeks after the second dose. The last dose in the series (third or fourth dose), must not be administered before age 24 weeks.
Hep B 1st
VARICELLA (CHICKENPOX)
Two (2) doses of varicella vaccine must be administered prior to entry. Dose one (1) must be administered on or after the first birth- day. The second dose should be administered at least three (3) months after dose one (1); however, if the second dose is adminis- tered at least 28 days after the first dose, it is considered valid.

One (1) dose of varicella vaccine must be administered on or after the first birthday.
1st
2nd
One (1) dose of meningococcal (serogroup A, C, W, and Y) vaccine must be administered prior to entry.
Two (2) doses of meningococcal (serogroup A, C, W, and Y) vaccine must be administered prior to entry.
1st
2nd
2112 Mock Road, Columbus, Ohio 43219
Legacy Academy
REQUEST FOR PERMANENT RECORDS
has enrolled in Valor Academy of Ohio (IRN#
and the student's first day is

PLEASE SEND THE FOLLOWING INFORMATION TO:

2112 Mock Road, Columbus, Ohio 43219 or email to LAE@legacy1870.com

Cumulative Records OAA Scores TGRG Results

Special Education (IEP, ETR, MFE)

Copy of Student's Data Form Expulsion/Suspension Documents Grade Card (or information about pupil placement)

Custody Records Third Grade Reading Results Birth Certificate/Passport Hearing/ Vision Results

TO BE COMPLETED BY PARENT OR GUARDIAN:
Name of school your child last attended
Is this school a Columbus Public School?

Yes No
If No, please name the DISTRICT
School Address
City
State
Zip
Student Last Grade Attended
PARENT/GUARDIAN AUTHORIZATION
Print Name: Parent/Guardian
SIGNATURE of Parent/Guardian

Clear
Date

Month Day Year
Date
According to the final regulations of the Family Education Rights and Privacy Act (Buckley Amendments to P.L.93.380) it is no longer necessary to obtain written consent from parents/guardians to release school records. School officials including teachers within the educational institution, and officials in other schools in which the student expects to enroll, may receive a student's records without consent from parents/guardians for such release.
1st Request
2nd Request
3rd Request
2112 Mock Road, Columbus, Ohio 43219
Legacy Academy
MEDICATION ADMINISTRATION REQUEST
The following student is under my care and should receive the medication indicated below. It is not possible to arrange for medication to be taken at home under the supervision of a parent, and therefore, must be taken during school hours.

ONLY LIST ONE MEDICATION PER FORM
Student Name
Student Address
City
State
Zip
Guardian Phone #
Name of prescribed medication
Dosage
Number of times/intervals medication is to be administered
Date administration to begin

Month Day Year
Date
Date administration to end

Month Day Year
Date
Adverse /sever reaction that should be reported to the physician?
Special instructions for administration of medication
The medication can be safely administered by non-medical personnel?

Yes No
Physician's Printed Name
Physician's Phone Number
Physician's Signature

Clear
Date

Month Day Year
Date
Parent's Signature

Clear
Date

Month Day Year
Date
2112 Mock Road, Columbus, Ohio 43219
Legacy Academy
MCKINNEY-VENTO HOMELESS FORM
Student Name
Date of Birth

Month Day Year
Date
Grade Level
The McKinney-Vento Homeless Assistance Act (Title X, Part C, of the No Child Left Behind Act) defines "homeless" as "individuals who lack a fixed, regular, and adequate nighttime residence.' This includes children who "are temporarily sharing the housing of other persons due to the loss of housing or economic hardship. "
Please check one of the following statements if your family is experiencing temporary homelessness:?

Living in a shelter, including transitional housing shelter; Student is awaiting foster care, etc.
Please provide name of shelter
Address

Living on the streets, abandoned buildings, in cars, trailers, campgrounds, public places, housing not fit for habitation Please provide information regarding area in which student is living: Living in hotels/motels for lack of other suitable housing Please list name and address of hotel/motel:
Address

Doubled-up; temporarily living with family or friends due to lack of adequate housing or financial conditions. Please provide address of where student is living:
Address
Living on the streets, abandoned buildings, in cars, trailers, campgrounds, public places, housing not fit for habitation Please provide information regarding area in which student is living:

Living in hotels/motels for lack of other suitable housing Please list name and address of hotel/motel:

Doubled-up; temporarily living with family or friends due to lack of adequate housing or financial conditions. Please provide address of where student is living:

Please answer the following if you checked one of the boxes above:
How long do you expect to be at this address?
Are you seeking permanent housing?

Yes No
Date student moved to this address

Month Day Year
Date
Is a parent living in the home with the student?

Yes No
If no, with whom is student living?
Relationship
We have read the information provided and indicated our living circumstances above with regard to the McKinney-Vento Act:

Print name of Parent/Guardian/Unaccompanied Youth:
Signature

Clear
Date

Month Day Year
Date
For Offical Use Only

Does Qualify under McKinney-Vento Act Does NOT Qualify
2112 Mock Road, Columbus, Ohio 43219
COLUMBUS
CITY SCHOOLS
Transportation Request
for
SCHOOL BUS EMERGENCY DOOR
Charter/Non-Public Schools
Charter/Non-public school students who reside within the boundaries of the Columbus City Schools District will request transportation to school by completing an online Transportation Request. Requests are made using our Infinite Campus Online Registration.
Register online visit 'Transportation at:
www.cCSoh.us/transportation.aspx
The slides will walk you
Infinite Campus Online Registration

Please complete the information below tob Parent/Guardian First Name Parent/Guardian Last Name Date of Birth (MM/DD/YYYY) Registration Year Email Address Previously Attended this District Confirmation Number Please type the two words you see displayed in the image below

Welcome to the district's Online Registration System! Please select whether you are starting a new application or if you are returning to finish an existing application.
through the online registration process. Each slide will prompt you for the information
proceed to the next step.
Infinite Campus Online Registration

Make sure to review each screens instructions

J Student(s) Primary Household Student Name Violet Parr Demographics

Therewill be few steps for each student you enter. The first general demographic information. Please verify or add the information below. Please update any information that incorrect. Please enter the student's name exactly as appears on the birth certificate If your student has two last names, please enter themarked box "last

First Name Middle Name Last Name Suffix Nickname Student Cell Number Student Email Address

Gender Enrollment Grade Birth Date 11/05/2004 Foreign Exchange O Yes, this foreign exchange student . No, this not foreign exchange student

Please select registration type:

Charter,Non-public Transportation Request

Columbus City Schools Registration
before continuing. Select Charter, Non- Public Transportation Request as the registration type. Don't forget to click 'Submit' when you are finished.
Race Ethnicity Relationships Previous Schools Cancel

Have Questions? Call Transportation 614-365-5074

Infinited Campus Online Registration

J Student(s) Primary Household

You must submit your application by clicking the following button. Submit PLEASE NOTE: Prior to submitting your application you may verify all of the data you have entered by going back to the area in question or click on the PDF link below. Your information is not submitted until you click the submit button above. You will receivean email notification that your application was received after clicking submit application. Back Application Summary PDF A Acrobat° Reader'
COLUMBUS
CITY SCHOOLS
File Upload

Cancel of
Signature

Clear
Should be Empty:

Legacy Academy

ENROLLMENT APPLICATION

Legacy Academy

ENROLLMENT APPLICATION

Legacy Academy

ENROLLMENT APPLICATION

PREVIOUS SCHOOL

SCHOOL #1

SCHOOL #2

SCHOOL #3

Legacy Academy

ENROLLMENT APPLICATION

SPECIAL SERVICES IEP

SPECIAL SERVICES 504

MCKINNEY-VENTO

MIGRANT WORKER

Legacy Academy

IMMUNIZATIONS

DTAP/DT TDAP/TD DIPHTHERIA, TETANUS, PERTUSSIS

POLIO

MMR MEASLES, MUMPS, RUBELLA

Legacy Academy

IMMUNIZATIONS

HEP B HEPATITIS B

VARICELLA (CHICKENPOX)

Legacy Academy

REQUEST FOR PERMANENT RECORDS

Legacy Academy

MEDICATION ADMINISTRATION REQUEST

Legacy Academy

MCKINNEY-VENTO HOMELESS FORM

COLUMBUS

CITY SCHOOLS

Transportation Request

for

SCHOOL BUS EMERGENCY DOOR

Charter/Non-Public Schools

Charter/Non-public school students who reside within the boundaries of the Columbus City Schools District will request transportation to school by completing an online Transportation Request. Requests are made using our Infinite Campus Online Registration.

Register online visit 'Transportation at:

www.cCSoh.us/transportation.aspx

The slides will walk you

through the online registration process. Each slide will prompt you for the information

proceed to the next step.

before continuing. Select Charter, Non- Public Transportation Request as the registration type. Don't forget to click 'Submit' when you are finished.

COLUMBUS

CITY SCHOOLS