Franklinton Prep High School Application

Emergency Medical Authorization
Student's Name*

First NameLast Name
Age
Address*

Street Address

Street Address Line 2

State / Province
City*
Zip*
State*
Student Phone Number*
Emergency Medical Authorized?*
Purpose - To enable parents and guardians to authorize the provision of emergency treatment for their student who becomes ill or injured while under the school's authority when parents or guardian cannot be reached.
Residential Parent or Guardian
Parent/ Guardian 1: Name

First NameLast Name
Parent/ Guardian 1: Phone Number
Parent/ Guardian 2: Name

First NameLast Name
Parent/ Guardian 2: Phone Number
Other: Name

First NameLast Name
Other: Phone Number
Part 1 - Grant Permission

I hereby give my consent for the following medical care providers and local hospital to be called:
Doctor's Name:
Doctor's Phone:
Dentist's Name:
Dentist's Phone:
Medical Specialist Name:
Medical Specialist's Phone:
Local Hospital Name:
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:
Additional Medical Information
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 actions:
Alternative Instructions
Parent/ Guardian/ Student 18 and older: *

First NameLast Name
Parent/ Guardian / Student 18 and older: Signature*

Clear

Appendix A: Language Usage Survey
Parents and Guardians: A completed language usage survey is required for all students open enrollment in Ohio schools. The information will tell school staff if they need to check the student's proficiency in English. Answers to these questions ensure the student 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 the student's education in a language they understand.
Family Preferred Communication Language
Language Background
Information about the student’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.
Student's first language?
Student's most used language
What languages are used in your home?
Prior Education
Responses about your student's birth country and previous education give us information about the knowledge and skills the student is bringing to school and may enable the school to receive additional funding to support the student.
In what country was the student born?
Has the student ever received formal education outside of the United States?

YesNo
If yes, how many years/months?
Has the student attended school in the United States?

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

MonthDayYear
Date
Additional Information: Please share additional information to help us understand the student's language experiences and background.
Language and Education Info
Parent/ Guardian/ Student 18 and older Name: *
Parent / Student 18 and older: Signature*

Clear

Media Release
TO BE COMPLETED BY PARENT, GUARDIAN OR ADULT STUDENT:
Name of Participating Student*

First NameLast Name
Age
Grade
I/we understand that as part of my/our student's attendance at Franklinton Prep High 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 student 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.
Student Name*

First NameLast Name
Student Signature*

Clear
Parent/ Guardian Name*
Parent Signature*

Clear

FERPA / Confidentiality and Communication 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, Franklinton Prep 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 Franklinton Prep High School. I hereby agree that my student's name and address may be provided to these entities to ensure that Franklinton Prep High School can best meet the educational needs of my student.

Confidentiality and Communication Consent:

As the parent/guardian, I agree to allow Franklinton Prep 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.
Student Name*

First NameLast Name
Student Signature*

Clear
Parent/ Guardian Name*

First NameLast Name
Parent/ Guardian Signature*

Clear

CAREER BASED INTERVENTION PROGRAM INFORMATION
As a Student at Franklinton Prep 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 Franklinton Prep High School Career Based Intervention Program, I agree to the following conditions:
As a condition of enrollment into the Career Based Intervention Program, I agree to the following conditions:
- 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.
- 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.
- 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.
- The Student must exercise good personal hygiene and be properly dressed and groomed per the direction of the School and the Student's employer.
- 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.
- The Student must report to any work experience in a timely manner and not loiter around the School once dismissed for the day.
- The Student must assume the responsibility of transportation to and from his or her work experience.
- 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 Franklinton Prep High School.
- 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.
- The Student understands that not fulfilling any of the above conditions may result in dismissal from the CBl Program and or loss of credits.

Franklinton Prep High School 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 Franklinton Prep High School Career Based Intervention Program, and that s/he will comply with the rules and regulations of the Program.
Student Name*

First NameLast Name
Student Signature*

Clear
I, the Parent/Guardian fully understand and agree with the goals, program requirements, and rules of the Franklinton Prep High School 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.
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear

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 by Title 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 current 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 Franklinton Prep 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.
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 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 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
Student Name*

First NameLast Name
Student Signature*

Clear
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 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 Franklinton Prep 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 Franklinton Prep High School dress code each day and that he/she has the necessary supplies and learning tools to class each day
Parent/Guardian/ Student 18 and older: Name*

First NameLast Name
Parent/Guardian/ Student 18 and older: Signature*

Clear

Family Education Services

Parent/Guardian/Student (over 18) 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/ Student 18 and older Name:*

First NameLast Name
Parent/Guardian/ Student 18 and older Signature*

Clear

Harassment, Intimidation, Bullying Policy
Please note that this High School has a “No Tolerance” Harassment, Intimidation, Bullying Policy. It is the policy of the school that no form of bullying behavior, whether it is in the classroom, on school property, to and from school or at school-sponsored events be permitted.

Students who have been determined to have engaged in prohibited behaviors are subject to disciplinary action, which may include suspension or expulsion from school. Misconduct by one student against another student, will result in appropriate disciplinary consequences for the perpetrator.
Please take the time to read more specifically about the School’s policy on harassment, intimidating and bullying in the student handbook, that set forth the comprehensive rules, procedures, and standards of conduct for the school and students.
Student Name*

First NameLast Name
Student Signature*

Clear
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear

Parent/Student Contract

Please review the contract before signing.
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
Student Name*

First NameLast Name
Signature*

Clear
Parent/ Guardian Name*

First NameLast Name
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

Additional Documentation

These additional documents will be required to complete registration and can be uploaded below or turned in to the School.
Student ID (if 18+ over)

Browse Files
ONLY from address at which the student is living Cancelof
Birth Certificate

Browse Files

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Social Security Card

Browse Files

Cancelof
Proof of Residency

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

Browse Files

Cancelof
Parent/Guardian ID

Browse Files
ONLY from address at which the student is living Cancelof
Parent / Guardian Photo ID

Browse Files

Cancelof
School Transcripts

Browse Files

Cancelof
Should be Empty:

Student Information

Parent / Guardian Information

Student's Family Data

Emergency Medical Authorization

Appendix A: Language Usage Survey

Media Release

FERPA / Confidentiality and Communication Consent

CAREER BASED INTERVENTION PROGRAM INFORMATION

Title 1 Compact

Student Agreement

FAMILY REPRESENTATIVE AGREEMENT

Family Education Services

Request for Records

Harassment, Intimidation, Bullying Policy

Parent/Student Contract

Additional Documentation