Enrollment Form - Old Brook

Enrollment Application

The following pages are to be completed as an Application of Enrollment for Old Brook High School. In order to fill this document out completely, you will need to have the following documentation: Proof of Residency, Birth Certificate, Immunization Records and School Transcripts. You are able to stop in the middle of the application and save and return to complete the application.
Student Information
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student's Primary Phone #
Student's Email
example@example.com
Parent's Primary Phone #
Parent's Primary Email
example@example.com
Social Security # (Optional)
Last 4 numbers of SSN (REQUIRED)
REQUIRED - if full # not provided
Student's Birth Date

MonthDayYear
Date
Gender

MaleFemale
Birthplace

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Native Language
US Citizen

YesNo
If No, list Nationality

Parent / Guardian Information

The following information should be completed referring to parent(s), and/or grandparent(s) with who the student resides:
Parent / Guardian

First NameLast Name
Relationship to Student
Occupation
Place of Employment
Work or Cell Phone #
Email
example@example.com
Parent / Guardian

First NameLast Name
Relationship to Student
Occupation
Place of Employment
Work or Cell Phone #
Email
example@example.com

Student's Previous Education
Does the student have a current or active Individualized Education Plan (I.E.P.)?

YesNo
Does the Student have an I.E.P.?

YesNo
If Yes, what school year?
If Yes, please provide a copy of the student's I.E.P. and Evaluation

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What year did the student start 9th grade?
List of Previous Schools

(Up to 5 - Middle and High School Only)
Previous School 1:
Previous School 2:
Previous School 3:
Previous School 4:
Previous School 5:
Please add any additional information that would be helpful for the school to know:

Additional Documentation

These additional documents will be required to complete registration and can be uploaded below or turned in to the School.
Proof of Residency

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Can include monthly utility bill, signed lease/rental agreement, monthly mortgage statement, rent receipt, paycheck with address on it or monthly bank statement. Cancelof
Birth Certificate

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Immunization Records

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School Transcripts

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Parent / Guardian Photo ID

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Parent / Student Contract
We have read and understand all of the information contained in the Parent/Student Handbook. By signing below, I/we agree to abide by and support the Old Brook High School rules and regulations, including the Code of Conduct and all other policies, as outlined in the Parent/Student Handbook. Although the Parent/Student Handbook reflects the current policies of Old Brook High School, it may be necessary to make changes from time to time to best serve the needs of our school and students.
Student Signature

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Student Name

First NameLast Name
Date

MonthDayYear
Date
Parent Signature (if student is under 18 yrs old.): I hereby state that the information provided in this document is true and current. I am the legal guardian or custodian of this student.

Clear
Parent / Guardian Name

First NameLast Name
Date

MonthDayYear
Date

Emergency Medical Authorization
Student's Name

First NameLast Name
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Purpose - To enable parents and guardians to authorize the provision of emergency treatment for their child who becomes ill or injured while under the school's authority when parents or guardian cannot be reached.
Residential Parent or Guardian
Mother's Name:

First NameLast Name
Daytime Phone:
Father's Name:

First NameLast Name
Daytime Phone:
Other's Name:

First NameLast Name
Daytime Phone:
Name of relative or childcare provider (other than parent):
PART 1 OR PART 2 MUST BE COMPLETED

Part 1 - Grant Permission

I hearby give consent for the following medical care providers and local hospital to be called.
Doctor's Name:

First NameLast Name
Phone:
Dentist's Name:

First NameLast Name
Phone:
Medical Specialist:

First NameLast Name
Phone:
Local Hospital
Phone:
In the event reasonable attempts to contact me have been unsuccessful I hereby give my consent for (1) the admission of any treatment deemed necessary by above named doctor; or the event the designated preferred practitioner is not available, by another licensed physician or dentist and (2) the transfer of the child to any hospital reasonably accessible.

This authorization does not cover major surgery sunless the medical options of two other licensed physicians or dentists concur in the necessity for such surgery are obtained prior to the performance of such surgery.

Facts concerning the child’s medical history including allergies, medications being taken, and any physical impairment to which a physician should be alerted:
Parent / Guardian Signature

Clear
Date

MonthDayYear
Date
Part 2 - Refusal to Consent

I do not give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the Old Brook High School authorities to take the following actions:
Parent / Guardian Signature

Clear
Date

MonthDayYear
Date

Appendix A: Language Usage Survey
Parents and Guardians: A completed language usage survey is required for all students upon enrollment in Ohio schools. This information will tell school staff if they need to check your child’s proficiency in English. Answers to these questions ensure your child receives the education services to succeed in school. The information is not used to identify immigration status.
Student Name

First NameLast Name
Student Date of Birth

MonthDayYear
Date
Communication Preferences

Indicate your language preference so we can provide an interpreter or translated documents at no cost when you need them. All parents have the right to information about their child’s education in a language they understand.
In what language(s) would your family prefer to communicate with the school?
Language Background
Information about your child’s language background helps us identify students who qualify for support to develop the language skills necessary for success in school. Testing may be necessary to determine if language supports are needed.
What language did your child learn first?
What language does your child use the most at home?
What languages are used in your home?
Prior Education
Responses about your child’s birth country and previous education give us information about the knowledge and skills your child is bringing to school and may enable the school to receive additional funding to support your child.
In what country was your child born?
Has your child ever received formal education outside of the United States?

YesNo
If yes, how many years?
If yes, what was the language of instruction?
Has your child attended school in the United States?

YesNo
If yes, when did your child first attend a school in the United States?

MonthDayYear
Date
Additional Information: Please share additional information to help us understand your child's language experiences and background.
Parent / Guardian Name

First NameLast Name
Parent / Guardian Signature

Clear
Date

MonthDayYear
Date
Thank you for providing the information above. Contact your school or district office if you have questions about this form or about services available at your child’s school. Translated information about schools’ civil rights obligations to English learner students and limited English proficient parents can be found here: https://www2.ed.gov/about/offices/list/ocr/ellresources.html

Media Release
TO BE COMPLETED BY PARENT, GUARDIAN OR ADULT STUDENT (Please print clearly):
Name of Participating Student

First NameLast Name
Age
Grade
School: Old Brook High School Location: Cleveland, OH 44109

I/we understand that as part of my/our child’s attendance at Old BrookHigh School (“School”), photos, videos, and quotations may be taken for use in publications and reports about the program. I/we further understand that members of the news media invited to cover the program may take photos, videos and quotations.

I/we grant permission to the School and its Board of Directors, Management Company, employees, agents and representatives to use such materials for the promotion of the program and to use this student’s name, photographic likeness, alone or in a group, in any publication, document, TV production, video or to release said name or likeness to any media outlets including, but not limited to, newspapers, magazines or TV stations for publicity and/or recognition purposes and/or to use this student’s name and/or photographic likeness, alone or in a group, on the official website of the School and/or
Management Company.

I agree that I and/or my child shall have no right, title, or interests in any photo or videotape covered by this agreement and waive any right to compensation for such use. I release the School, its Board of Directors, the Management Company, employees, agents, representatives and all organizations and individuals related to the School from any and all liabilities or damages that result from the use of this student’s name and/or photographic likeness as described above.
Signature of Parent / Guardian

Clear
Date

MonthDayYear
Date
Signature of Student (if 18 years old)

Clear
Date

MonthDayYear
Date

FERPA / Confidentiality and Communication Consent
FERPA Consent:

The Family and Educational Rights and Privacy Act (FERPA) provides parents and students over 18 years of age ("eligible students") certain rights regarding the student’s educational records. In order to serve the student's educational needs, Old Brook High School may find it necessary to disclose a student's name and address to a vendor to provide them with the appropriate learning solutions. These vendors agree to the confidentiality of the student's name and address and will not use such information for any purpose other than those required under their vendor contract with Old Brook High School. I hereby agree that my student's name and address may be provided to these entities to ensure that Old Brook High School can best meet the educational needs of my student.

Confidentiality and Communication Consent:

As the parent/guardian, I agree to allow Old Brook High School personnel the right to contact me or my student in any manner of communication that pertains to the student's academic well-being. This may include, but is not limited to: Director, Assistant Directors, Teachers, Family Advocate, Employability Specialists, Administrative Assistants, and EMIS/Student Data Specialists. This information will remain confidential except in cases where there is an ethical and or legal responsibility to limit the above said confidentiality.
Signature of Parent / Guardian

Clear
Date

MonthDayYear
Date
Signature of Student (if 18 years old)

Clear
Date

MonthDayYear
Date

CAREER BASED INTERVENTION PROGRAM INFORMATION
As a Student at Old Brook High School, you will be participating in a Career Based Intervention Program. This Program allows the Student to earn high school credits for time spent at work. In order to receive the appropriate amount of credits for work, the Student must regularly provide the School with employment information including but not limited to the name and address of the employer, the amount of time worked per pay period, the date of termination/last date worked, and efforts made to obtain new or previous employment. Failure to provide appropriate documentation will prevent the Student from earning the corresponding credits. All Students are required to complete all regular academic coursework. Additionally, Students under the age of 18 must have a valid work permit.

STUDENT AND PARENT CONTRACT FOR CAREER BASED INTERVENTION

The Career Based Intervention (CBI) Program is designed to give students the opportunity to complete their education while learning the obligations of the world of work. The success of students in the CBI Program is dependent upon their desire to improve. There are definite responsibilities the STUDENT must agree to carry out before being enrolled:
As a condition of enrollment into the Old Brook High School Career Based Intervention Program, I, First Name Last Name ,agree to the following conditions:
Como condición para participar en este programa de Intervención Basado en Carreras Técnicas de la escuela Old Brook High School, Yo,First Name Last Name, acepto las siguientes condiciones:
1. To be in school every day and on time unless excused from school.
  If in a paid work experience, to be at work on time and to miss work only if excused by the employer, school, or parent.
2. If it is necessary to miss a scheduled shift at work, the student agrees to notify the employer in a timely and courteous manner, prior to the time that the student was supposed to begin working his or her shift.
3. The Student must notify the School immediately of any school or work problems and accept the designated staff member's counseling, guidance, and any reassignments or adjustment of the Student's work experience.
4. The Student must exercise good personal hygiene and be properly dressed and groomed per the direction of the School and the Student's employer.
5. The Student must understand that s/he may be dropped from the program if s/he cuts a class, lies, cheats, steals, fails a class, or is fired from a paid work experience.
6. The Student must report to any work experience in a timely manner and not loiter around the School once dismissed for the day.
7. The Student must assume the responsibility of transportation to and from his or her work experience.
8. The Student agrees to make an honest effort to succeed in all academic subjects and at work and to perform all academic and work obligations in a manner that will reflect positively on self and Old Brook High School.
9. The Student agrees to immediately notify the School of any changes in employment, rate of pay job description, full or part time work status, and residency.
10. The Student understands that not fulfilling any of the above conditions may result in dismissal from the CBl Program and or loss of credits.
The Old Brook High School's Career Based Intervention Program affords the Student the ability to attend school for a shorter time period each day than the required four and one-half hour session. ONLY STUDENTS WHO ARE REGULARLY WORKING MAY TAKE ADVANTAGE OF THIS PRIVILEGE. IF A STUDENT IS NOT REGULARLY WORKING, THE STUDENT MUST ATTEND THE FULL 4.5 HOUR SESSION.

By signing below the Student acknowledges that s/he will be participating in the Old Brook High School's Career Based Intervention Program, and that s/he will comply with the rules and regulations of the Program.
Signature of Student

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Date

MonthDayYear
Date
I, First Name Last Name , the Parent/Guardian fully understand and agree with the goals, program requirements, and rules of the Old Brook High School's Career Based Intervention Program. I will fully cooperate with the school to accomplish the goals and to ensure that the requirements are met and the rules are adhered to by my Student. I give my permission for my Student, to participate in the Career Based Intervention Program at this school.
Yo, First Name Last Name, padre/madre o guardián entiendo y apoyo las metas, reglas y requerimientos del programa de Intervención basado en Carreras Técnicas. Cooperar con la escuela para cumplir dicho acuerdo y asegurar que los requerimientos y reglas sean respetados por mi estudiante. Por lo tanto autorizo a mi estudiante a participar en dicho programa en esta escuela.
Signature of Parent / Guardian

Clear
Date

MonthDayYear
Date

Old Brook High School - Title 1 Compact
What is a “school-parent compact?

Each Title I, Part A School must jointly develop, with the parents of children served under Title I, Part A, a school-parent compact as a component of its written parental involvement policy. A school-parent compact is a written agreement between the school and the parents of children participating in Title I, Part A programs that identifies the activities that the parents, the entire school staff, and the students will undertake to share the responsibility for improved student academic achievement, in addition, the school-parent compact outlines the activities that the parents, school staff, and students will undertake to build and develop a partnership to help the children achieve to the State’s high academic standards.

What information and opportunities must schools provide parents of children participating in Title I, Part A programs?

Schools served under Title I, Part A must provide to parents of participating children, in a timely manner, information about the programs, funded by Title I, Part A. That information must include:
• A description and explanation of the school’s curriculum;
• Information on the forms of academic assessment used to measure student progress; and
• Information on the proficiency levels students are expected to meet.

Upon the request of parents, schools must provide the opportunities for regular meetings for parents to formulate suggestions and to participate, as appropriate, in decisions about the education of their children. The school must respond to any suggestions as soon as practicably possible.

The School, the students, and the parents of the minor students participating in activities, services, and programs funded byTitle I, Part A of the Elementary and Secondary Education Act (ESEA), agree that this compact outlines how the parents, the entire school staff, and the students will share the responsibility for improved student academic achievement and the means by which the school and parents will build and develop a partnership that will help children achieve the State’s high standards.

This school-parent compact is in effect during the 2022-2023 school year. The purpose of this Compact, found in Section 118 of Public Law 103-382, is to build and foster development of the school-student partnership to help all students achieve the State of Ohio’s high standards. Parent/Guardians, students, and teachers will share the responsibility for improved student achievement.
Each student is responsible for his or her own academic progress in mastering the necessary skills in order to complete the academic program at Old Brook High School.
• The school will provide high-quality curriculum and instruction in a supportive and effective environment that enables all students to meet the State’s student performance standards.
• The school will provide students and parents of minor children with reports on their children’s progress.
• The school will provide parents with opportunities to volunteer, observe, and participate in their child’s learning.

• The school will provide reasonable access to staff through parent/teacher conferences and consultations.
Old Brook High School - Title 1 Compact

Student Agreement
Communication between the Student and the School staff is important. As a student who has responsibility for his or her own education, I will attend the daily sessions on a regular basis and do all that is asked of me at the School to the best of my abilities.

I, First Name Last Name , agree to Title I service for myself and that I will be responsible for supporting my learning in the following ways:
- Attending school regularly and punctually
- Being prepared to learn by being well-rested, fed and dressed according to the Old Brook High School dress code each day
- Being prepared to learn by bringing the necessary supplies and learning tools to class each day
- Working on learning activities including computer-based learning, teacher-led, and vocational education to the best of my abilities
- Asking questions when I do not know something
- Supporting the school in efforts to maintain proper discipline
- Respecting all school staff, my fellow students, and the cultural differences of others
La comunicación entre el estudiante y el personal de la escuela es muy importante. Como responsable de mi propia educación asistiré de manera regular y cumpliré con las asignaturas de la mejor manera posible.

Yo, First Name Last Name , estoy de acuerdo con el Título 1 y lo apoyaré de la siguiente forma:
- Asistiré a la escuela y seré puntual
- Cada dia llegaré bien preparado, descansado, comido y vestido de acuerdo al código de vestuario de la escuela Frederick Douglass
- Me presentaré listo (a) para aprender y traeré los útiles escolares necesarios, cada dia
- Trabajaré en las actividades de aprendizaje incluyendo, en computadora, instrucción de maestros, y vocacional de la mejor manera que me sea posible
- Haré preguntas cuando no entienda algo
- Apoyaré a mi escuela en mantener la disciplina
- Respetaré al personal escolar, a mis compañeros, y las diferencias culturales de los demás
Signature of Student

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Date

MonthDayYear
Date
FAMILY REPRESENTATIVE AGREEMENT

Communication between the home and the School staff is important. As a parent or adult who has responsibility for the above-named student, I will attend at least one parent/teacher conference during which this Compact will be discussed as it relates to my child’s achievement. I will read each progress report and talk to my child about the progress report. I understand that I will have reasonable access to my child’s teachers, and will be able to observe classroom activities.
I, First Name Last Name , agree to Title I service for my child and that I will be responsible for supporting learning of my child in the following ways:
- Reading Progress Reports
- Discussing Progress Reports with my child
- Participating in parent/teacher conferences
- Monitoring my child’s school attendance
- Assisting my child in learning to resolve conflicts in positive ways
- Supporting the school in efforts to maintain proper discipline
- Respecting all Old Brook High School staff and students, and the cultural differences of others
- Assuring that my child is prepared to learn by being well-rested, fed and dressed according to the Old Brook High School dress code each day and that he/she has the necessary supplies and learning tools to class each day
La comunicación entre el personal escolar y la familia del estudiante es muy importante. Como padre o guardián responsable del estudiante asistiré por lo menos a una junta de padres/maestros donde este acuerdo será discutido, ya que ayudará al éxito de mi estudiante. Leeré los reportes académicos y hablaré con mi estudiante sobre ellos. Entiendo que tengo acceso a los maestros de mi estudiante y puedo observar clases y actividades.

Yo, First Name Last Name , estoy de acuerdo con este convenio - Titulo 1 para mi estudiante y que seré responsable en apoyar el progreso académico de mi estudiante en:
- Leer los reportes de progreso escolar
- Participar en las juntas de padres/maestros
- Monitorear la asistencia a clases de mi estudiante
- Apoyar a mi estudiante a aprender a resolver conflictos de una manera positiva
- Apoyar a la escuela en sus esfuerzos de mantener la disciplina
- Respetar al personal de la escuela Frederick Douglass, sus estudiantes y las diferencias culturales de los demás
- Me aseguraré que mi estudiante esté listo para aprender, bien descansado, comido y vestido de acuerdo al código de conducta de Frederick Douglass, incluyendo, útiles y materiales escolares necesarios
Signature of Family Representative

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Date

MonthDayYear
Date

Family Education Services

Parent/Guardian Consent for Individual and Group Services
Your permission is requested for your child to participate in individual advising sessions and group activities. This time will be used to discuss ideas, behaviors, feelings, attitudes, and opinions of the student.

Because advising is based on a trusting relationship between the Advocate and the student, the FES Advocate will keep the information shared in the sessions confidential except in certain situations in which there are an ethical and/or legal responsibility to limit confidentiality. In the following circumstances you will be notified.

1. If the child reveals information about hurting himself/herself or another person.

2. If the child reveals information about child abuse.

3. Other situations that ethically and/or legally compel disclosure.

By signing this form I give my informed consent for my child to participate in individual advising sessions and group activities. I understand that

1. This time will be utilized to strengthen interpersonal skills, discuss feelings, share idea, practice new behaviors, and build self-esteem.

2. Anything that is shared during this time will be kept confidential by the Family Advocate except in the above-mentioned cases.
Parent / Guardian Name

First NameLast Name
Date

MonthDayYear
Date
Signature of Parent / Guardian

Clear
Parent / Guardian Name

First NameLast Name
Date

MonthDayYear
Date
Signature of Parent / Guardian

Clear
Student Name

First NameLast Name
Date

MonthDayYear
Date
Student Signature

Clear
Return to:

First NameLast Name

Enrollment Application

Student Information

Student Ethnicity

Student's Family Data

Parent / Guardian Information

Student's Previous Education

List of Previous Schools

Additional Documentation

Parent / Student Contract

Emergency Medical Authorization

Appendix A: Language Usage Survey

Media Release

FERPA / Confidentiality and Communication Consent

CAREER BASED INTERVENTION PROGRAM INFORMATION

Old Brook High School - Title 1 Compact

Old Brook High School - Title 1 Compact

Family Education Services

Request for Records