Enrollment Form - Orchard Park Academy

Proof of Residency

Please attach an updated Proof of Residency if residency has changed. (Current utility bill, voter registration, lease agreement, etc. with current address)
Proof of Residency

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Primary Contact 1 Signature

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Primary Contact 1 Name

First NameLast Name
Primary Contact 2 Signature

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Primary Contact 2 Name

First NameLast Name

Emergency Medical Authorization Form
Purpose: To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under school authority, when parents or guardians cannot be reached. This information will be shared, as necessary, with teachers, bus drivers, administrative staff, health personnel including student nurses, and other school personnel. ORC 3313.712
Student Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Grade*
Home Phone*
Mother or Guardian Name*

First NameLast Name
Mother or Guardian Home Phone*
Mother or Guardian Cell Phone*
Father or Guardian Name

First NameLast Name
Father or Guardian Home Phone
Father or Guardian Cell Phone
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contacts
Name 1*

First NameLast Name
Relationship to Student*
Daytime Phone Number*
Cell Phone Number*
Name 2

First NameLast Name
Relationship to Student
Daytime Phone Number
Cell Phone Number
Name 3

First NameLast Name
Relationship to Student
Daytime Phone Number
Cell Phone Number
Name 4

First NameLast Name
Relationship to Student
Daytime Phone Number
Cell Phone Number
Provide ANY pertinent medical history or information about existing conditions that may affect your child at school.
Medical Information
Medications
Does the student have diabetes?*

YesNo
Does the student require the use of an inhaler?*

YesNo
Allergies
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 Name

First NameLast Name
Doctor Phone Number
Dentist Name

First NameLast Name
Dentist Phone Number
Medical Specialist Name

First NameLast Name
Medical Specialist Phone Number
Local Hospital/Emergency Room
Hospital/Emergency Room Phone Number
Parent / Guardian Signature

Clear
Parent / Guardian

First NameLast Name
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 school authorities to take the following action:
Parent / Guardian Signature

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Parent / Guardian

First NameLast Name
Date

MonthDayYear
Date
In the event reasonable attempts to contact me have been unsuccessful, I hearby give my consent for:

1. The administration of any treatment deemed necessary by above named doctors, or, in the event the designed practitioner is not available, by another licensed physician or dentist:

2. The transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

Immunization Information

For information regarding current immunization requirements go to www.odh.ohio.gov Immunizations : Required Vaccines for Schools
One of these must accompany the EIIR card at all times (select all that apply):

Copy of current official documented immunization record attachedReligious Beliefs exemption form signed by parent/guardian attachedMedical exemption form signed by physician and parent/guardian attachedSigned Laboratory Proof of Immunity form attached
Is the child allergic to food or other substances? (If yes, describe symptoms, name foods or substances to be avoided and the procedure to follow if reaction occurs.)
Is the child usually susceptible to infections and, if so, what precautions need to be taken? (If yes, list precautions)
Is child subject to convulsions and what should be our procedure if one occurs? (if yes, specify procedure)
Is there any physical condition that we should be aware of and what precautions should be taken (heart trouble, foot problem, hearing impairment, hernia, etc.) (if yes, list precautions)
If you have answered "yes" to any of the above, please provide a written action plan in case of medical emergency for your student. Blank action plans are available at the front office.
Other Special Instructions:
This Emergency Information and Immunization Record Card is accurate and complete and was provided by:
Parent/Guardian Signature*

Clear
Parent/Guardian*

First NameLast Name
Date*

MonthDayYear
Date

Media Release Form
Student Name

First NameLast Name
Grade
Date of Birth

MonthDayYear
Date
Home Phone Number
Mother's Name

First NameLast Name
Phone Number
Father's Name

First NameLast Name
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I, Parent / Legal Guardian of (Child's Name) blanks hereby grant permission to Orchard Park Academy, its agents and assigns, to use above named child's photo or video, and likeness for the purpose of promotion of Orchard Park Academy for all forms, media and manners, for the following, but not limited to, news releases, photographs, video, audio, website, marketing, advertising, trade, promotion, exhibition for an indefinite period of time.

I give unrestricted permission for images, videos, and recordings of the child to be used in print, video, digital and internet media. I agree that these images and/or voice recordings may be used for a variety of purposes and that these images may be used without further notifying me.

I further acknowledge that I will not be compensated for these uses and the Orchard Park Academy owns all rights to the images, videos and recordings, and to any derivative words created from them.

I waive any right to inspect the uses of any printed or electronic copy. I hereby release Orchard Park Academy and its agents and assigns from any claims that may arise from these uses, including without limitation claims of defamation or invasion of privacy, or of infringement of moral rights or rights of publicity or copyright.

This release expresses the complete understanding of the parties.
Signature

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Name

First NameLast Name
Relationship
Date

MonthDayYear
Date

Activity Authorization Form
I hereby authorize the release and disclosure of the personal health information of
First Name Last Name ("Student"), as described below, to Type a label
("School"). The information described below may be released to the School principal or assistant principal, coach, physical education teacher, school nurse or other member of the School's administrative staff as necessary to evaluate the Student's eligibility to participate in school sponsored activities, including but not limited to interscholastic sports programs, physical education classes or other classroom activities.
Personal health information of the Student which may be released and disclosed includes records of physical examinations performed to determine the Student's eligibility to participate in school sponsored activities, including but not limited to the Pre-participation Evaluation form or other similar document required by the School prior to determining eligibility of the Student to participate in classroom or other School sponsored activities; records of the evaluation, diagnosis and treatment of injuries which the Student incurred while engaging in school sponsored activities, including but not limited to practice sessions, training and competition; and other records as necessary to determine the Student's physical fitness to participate in school sponsored activities.
The personal health information described above may be released or disclosed to the School by the Student's personal physician or physicians; a physician or other health care professional retained by the School to perform physical examinations to determine the Student's eligibility to participate in certain school sponsored activities or to provide treatment to students injured while participating in such activities, whether or not such physicians or other health care professionals are paid for their services or volunteer their time to the School; or any other EMT, hospital, physician or other health care professional who evaluates, diagnoses or treats an injury or other condition incurred by the student while participating in school sponsored activities.
I understand that the School has requested this authorization to release or disclose the personal health information described above to make certain decisions about the Student's health and ability to participate in certain school sponsored and classroom activities, and that the School is a not a health care provider or health plan covered by federal HIPAA privacy regulations, and the information described below may be re-disclosed and may not continue to be protected by the federal HIPAA privacy regulations. I also understand that the School is covered under the federal regulations that govern the privacy of educational records, and that the personal health information disclosed under this authorization may be protected by those regulations.
In understand by its nature, participation in interscholastic athletics includes risk of injury and transmission of infectious disease such as HIV and Hepatitis B. Although serious injuries are not common and the risk of HIV transmission is almost nonexistent in supervised school athletic programs, it is impossible to eliminate all risk. Participants have a responsibility to help reduce that risk. Participants must obey all safety rules, report all physical and hygiene problems to their coaches, follow a proper conditioning program, and inspect their own equipment daily.
I understand that in the case of injury or illness requiring transportation to a health care facility that a reasonable attempt will be made to contact the parent or guardian in the case of the student-athlete being a minor, but that, if necessary, the student-athlete will be transported via ambulance to the nearest hospital.
I also understand that health care providers and health plans may not condition the provision of treatment or payment on the signing of this authorization; however, the Student's participation in certain school sponsored activities may be conditioned
on the signing of this authorization.
I consent to the use of the herein named student's name, likeness, and athletic-related information in reports of contests, promotional literature and other materials and releases related to interscholastic athletics.
This authorization will expire at the conclusion of the present school year.
Student Signature*

Clear
Student Name

First NameLast Name
Date*

MonthDayYear
Date
Birth Date*

MonthDayYear
Date
Grade in School*
Parent / Guardian Signature*

Clear
Parent / Guardian Name*

First NameLast Name
Date*

MonthDayYear
Date

Request for Records
Date of Request*

MonthDayYear
Date
Last School of Attendance:*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Fax Number
Student's Name:*

First NameLast Name
Student's Date of Birth*

MonthDayYear
Date
Please release the following

Birth CertificateDisciplinary RecordsImmunization / Health RecordsOfficial TranscriptsPermanent / CumulativeSpecial Education Records / IEP / Multi-Factored EvaluationsTesting RecordsOther
Parent / Guardian Signature*

Clear
Parent / Guardian Name

First NameLast Name
Mail or Email request to:

Orchard Park Academy (IRN 016837)

14440 Triskett Rd

Cleveland, OH 44111

Phone: 440-340-3202

Email: enrollment@orchardparkacademy.org

Language Usage Summary

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 isn't 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 and translated documents at no cost when you need them. All parents have the right to information about their child's education in language they understand.
1. 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 languagae skills necessary for success in school. Testing may be necessary to determine if language supports are needed.
2. What language did your child learn first?
3. What language does your child use the most at home?
4. 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.
5. In what country was your child born?
6. Has your child ever received formal education outside of the United States?

YesNo
If yes, how many years/months?
If yes, what was the language of instruction?
7. 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 educational background.
Parent / Guardian Name:

First NameLast Name
Parent / Guardian Signature

Clear
Today's 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.
Should be Empty:

Enrollment Application

Student Information

Student Release Form

Proof of Residency

Emergency Medical Authorization Form

Immunization Information

Media Release Form

Activity Authorization Form

Request for Records

Language Usage Summary