MADISON VIRTUAL ACADEMY STUDENT ENROLLMENT FORM

Parents/Guardians of Madison County Virtual Academy Students:

A full enrollment packet is needed for all MCVA students to ensure all necessay forms are on file in order to complete enrollment and for times when an MCVA student will need to attend in person for scheduled meetings or required testing. Please complete and submit the following enrollment forms.

Thank you.

Rows	Name	Relationship to Student Enrolling
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CURRICULUMAND INSTRUCTION 08.2323 AP.21
(CONTINUED)

Electronic Access/User Agreement Form

CONSENT FOR STUDENT USE

By signing this form, you hereby accept and agree that your child’s rights to use the electronic and physical resources provided by the District and/or the Kentucky Department of Education (KDE) are subject to the terms and conditions set forth in District policy/procedure. Data stored in relation to such services is managed by the District pursuant to policy 08.2323 and accompanying procedures. You also understand that the e-mail address provided to your child can also be used to access other electronic services or technologies that may or may not be sponsored by the District, which provide features such as online storage, online communications and collaborations, and instant messaging. Use of those services is subject to either standard consumer terms of use or a standard consent model. Data stored in those systems, where applicable, may be managed pursuant to the agreement between KDE and designated service providers or between the end user and the service provider. Before your child can use online services, your child must accept the service agreement and, in certain cases, obtain your consent.

_________________________________________________________
As a student of Madison County Schools, I understand and agree to follow the rules as stated in the Acceptable Use Policy above
Signature
Student First Name
Student Last Name:
Date

MonthDayYear
Date
School
Grade:
As the parent/guardian of the above student, I understand and agree to the Acceptable Use Policy as stated above and referenced in board policy 08.2323 and accompanying procedures (available at www.madison.kyschools.us). I understand that this consent will remain in effect until the student is no longer enrolled in a Madison County school unless I rescind consent in writing.
Signature
Parent Name:
Date

MonthDayYear
Date

Madison County Schools Transportation Verification Form
Each year at the beginning of school and again in January, the school is required to verify the transportation code for each student. Please verify the correct code for your child and return the completed form to the school office as soon as possible. If not completed by the student or parent/guardian, then a school official (teacher, clerk or other) may interview the student and complete this form for correct data entry.

The following is an explanation of transportation codes:

NT= students who are NOT transported by the Madison County School System

T1= students who are transported by the Madison County School System OVER 1 mile to and from school

T2= students who are transported by the Madison County School System UNDER 1 mile to and from school

T3= students who are transported by Madison County School System OVER 1 mile only ONCE daily

T4= students who are transported by the Madison County School System UNDER 1 mile only ONCE daily

T5= students who are approved for special transportation accommodations (documentation required in student's IEP)

If your child’s transportation changes from day to day, please check the code which your child uses
(3) Student First Name*
(2) Student Last Name*
(7) Street Address*
(8) City*
(9) Zip Code*
Mailing Address if different from above
Parent Guardian Home Phone
Format: (000) 000-0000.
Parent Guardian Cell Phone
Format: (000) 000-0000.
NTT1T2T3T4T5
Madison County Schools is committed to nondiscrimination on the basis of race, color, national origin, age, religion, marital status, sex or disability in educational programs, activities and employment as set forth in compliance with federal and state guidelines. Responsibility for coordination of compliance efforts and receipt of inquiries concerning the guidelines above may contact the Director of Human Resources, Madison County Schools 301 Highland Park Dr., Richmond, KY
REGULATIONS FOR PUPILS RIDING MADISON COUNTY SCHOOL BUSES
Student First Name
Student Last Name
THE PRIVILEGE OF ANY PUPIL TO RIDE A SCHOOL BUS IS CONDITIONED UPON THEIR GOOD BEHAVIOR AND OBSERVANCE OF THE FOLLOWING RULES AND REGULATIONS. ANY PUPIL WHO VIOLATES ANY OF THESE RULES OR REGULATIONS WILL BE REPORTED TO THE PRINCIPAL OF THE SCHOOL WHICH THE PUPIL ATTENDS FOR NECESSARY CORRECTIVE ACTION.

1.  The driver is in full charge of the bus and the pupils. Pupils shall obey the driver courteously and promptly.

2.  Pupils shall occupy the space designated for them by the driver.

3.  Pupils shall be on time, the bus cannot wait for those who are not on time.

4.  Pupils are never to stand in the road while waiting for the bus.

5.  Pupils are to clean their feet before entering the bus.

6.  Pupils shall not spit on the bus.

7.  Pupils are not to throw waste paper or rubbish on the floor of the bus.

8.  Pupils are not to mar or otherwise deface the bus.

9.  Pupils are not allowed to carry a knife or any sharp instrument on the bus. If done the driver will take the knife or instrument to the principal’s office.

10.  Pupils are not to start to school when sick or when any member of the family has a contagious disease.

11.  The following activities are prohibited at all times:

a.Improper behavior to include: insolence, disobedience, vulgarity, foul language, fighting, pushing, shoving and similar offensive acts.

b.The use of tobacco in any form (smoking, chewing, dipping, snuff)

c. Eating or drinking on the bus

d. Throwing articles or objects in or from the bus.

e. Tampering with mechanical equipment, accessories or controls of the bus.

f. Placing musical instruments or other articles at the door by the driiver.

g. Obstructing the aisle in any manner.

h. Occupying more space in a seat than required.

     i. Opening or closing windows without permission of driver

j. Toys, electronic games, radios

12.  Pupils are to avoid unnecessary conversations with the driver

13. Pupils at all times are to keep arms and head inside the bus windows.

14. Pupils are not to leave the bus without the driver’s consent except at home or at school.

15. Pupils are not to leave their seats unless getting on or off the bus unless authorized by the driver.

16. Pupils are to respect persons whom they pass on the routes.

17. Pupils are to report to the driver at once any damages to the bus.

18. Pupils are to walk on the left side of the road, facing the bus and not behind it.

19. Pupils who must cross the road after alighting from the school bus shall pass in front of the bus and not behind it.

20. The driver shall see that the way is clear before the child is permitted to cross the road.

21. Should the conduct of a pupil on the bus endanger the lives or morals of other people, and offending pupils to cease such conduct when requested by the driver to do so, it shall be the duty of the driver to put the offender off the bus and report his action to the principal immediately. This should be done only in extreme cases and as a last resort to protect the Principal, Superintendent or Director of Transportation.

22. Any pupil who violates any of these rules and regulations may be reported to the principal of the school he or she attends for disciplinary action.

PARENTS & GUARDIANS: KEEP THESE REGULATIONS DURING THE TIME THE STUDENTS ARE IN SCHOOL.

WARNING: CLOTHING DRAWSTRINGS AND STRAPS OF ANY KIND CAN BE DANGEROUS AND MAY HANG IN SCHOOL BUS DOORS AND HANDRAILS. REMOVE, SHORTEN OR REPLACE WITH A SAFE TYPE OF FASTENER. PLEASE SIGN BELOW AND RETURN TO THE PRINCIPAL OF THE SCHOOL YOUR CHILD ATTENDS IN ORDER FOR YOUR CHILD TO CONTINUE RIDING THE SCHOOL BUS.
For Middle School and High School Students Only:
I have read and understand the REGULATIONS FOR PUPILS RIDING SCHOOL BUSES and agree, as a passenger, to abide by said regulations.
(5) Grade
For the Parent or Guardian:
I have read and understand the REGULATIONS FOR PUPILS RIDING SCHOOL BUSES and agree, as a passenger to abide by said regulations.
(12) Parent/Guardian First Name*
(13) Parent/Guardian Last Name*
Parent/Guardian Signature*
(3) Student First Name*
(2) Student Last Name*

Publication Form for Photos,Videos, Interview and Web Publication

09.14 AP.251

PERMISSION FOR MEDIA USE, DISTRICT BROADCAST,WEB OR OTHER PUBLICATION OF STUDENT’S PHOTOGRAPH, LIKENESS, AND/OR VOICE

Throughout the year, there may be in-school programs, events, assemblies, PTA/PTO events that are open to the public and where large group photographs or videos will be taken by the media and/or school/district staff.

In addition, to the above situations, there may be times the media (newspaper, television, or radio), school district staff, or students (as part of class projects and activities) may take photographs, audio/videotape students, or interview students individually. The school district may display student pictures and projects in a variety of ways that reasonably portray programs of the Madison County Schools, including pictures of field trips, science fairs, sports events, and other activities appearing in yearbooks or school/district publications. Student likeness and work may also appear on the district website, thereby making it available to the public.

The school district assumes no responsibility for photographs, audio/videotapes, etc. that may be made by parents or other non-school personnel at public events.
I GIVE permission for my child to be photographed, audio/videotaped, or interviewed. I understand that this permission covers all academic, sporting, and school events/activities as related to the Madison County Schools.I DO NOT GIVE permission for my child to be photographed, audio/videotaped, or interviewed, and understand that this may prevent awards and recognition programs from including my child.
(3) Student First Name*
(2) Student Last Name*
(14) Date

MonthDayYear
Date
(1) School:
Parent/Guardian Signature*
(12) Parent/Guardian First Name*
(13) Parent/Guardian Last Name*
Once signed and dated, this form shall remain in effect throughout the student’s attendance in the building in which his/her grade level is housed and kept on file by the Principal or School Technology Coordinator. However, at any time during the school year, you may amend this form only by notifying the Principal in writing of your request.

Review/Revised: 10/21/2021

Madison County Schools

Home Language Survey
Dear Parent/Guardian:

The purpose of the home language survey (HLS) is to determine the primary or home language of the student. This information is essential in order for schools to provide meaningful instruction for all students. The HLS is part of the statewide identification process required under Section 3113(b)(2) of the Every Student Succeeds Act (ESSA) and 703 KAR 5:070 and the related Inclusion of Special Populations Guidance.

The HLS must be given to all students in grades K-12 upon their initial enrollment in the district as a first screening process to identify potential English learner students. The HLS is administered one time, upon initial enrollment in grades K-12 and remains in the student’s cumulative file.

Please note that the answers to the survey below are student-specific. If a language other than English is recorded for ANY of the required survey questions below, the district is legally obligated to do further assessment of your child to determine if they are eligible for language support.

Answers will not be used for determining legal status or for immigration purposes. If your child is identified for English language services, you may decline some or all of the services offered to your child.

If you have any questions on how to complete the HLS, please contact your child’s school.
Student Information (required):
(3) Student First Name*
(2) Student Last Name*
(5) Grade
Student Language Background (required):
1. What is the language most frequently spoken at home?*
2. Which language did your child learn when they first began to talk?*
3. What language does your child most frequently speak at home?*
4. What language do you most frequently speak to your child?*
Language for School Communication (not required):
5. In which language would you prefer to receive all school information:
(12) Parent/Guardian First Name*
(13) Parent/Guardian Last Name*
Signature*
(14) Date

MonthDayYear
Date
By signing here, you certify that responses to the four required questions above are specific to your student. You understand that if a language other than English has been identified, your student will be tested to determine if they qualify for language support services, to help them become fluent in English. Students qualifying for language support services are entitled to services as an English learner and will be tested annually to determine their English language proficiency as required by ESSA 1111(b)(2)(G).
(1) School student is enrolling in (choose from list)
Choose districted school from drop down list above

Kentucky Parental Notice for One Time Consent to Allow the School District to Access Kentucky Medicaid Benefits
School District Name: Madison County Schools

School/District Contact:Jackie Mahaffey/859-625-6044

The purpose of this letter is to ask for your permission to release information needed to recover costs from Medicaid for eligible school-based services. Local education agencies in Kentucky have been approved to receive partial reimbursement from Kentucky’s Department for Medicaid Services (DMS) for the costs of certain health-related services provided by the district to your child (or children

With your permission, the school district will be able to seek partial reimbursement for medically necessary services to Medicaid recipients in accordance with an Individualized Education Program (IEP), an Individual Family Service Plan (IFSP), or are otherwise medically necessary.

The school district will need to share following types of information about your child: name, date of birth; gender; social security number, Individual Education Plan, Service records and any relevant information. Each year, the district will provide you with notification regarding your permission; you do not need to sign a form every year.

The school district cannot share information about your child without your permission. When you give permission, please be advised of the following:

1.This will allow the release of information, for the sole purpose of billing Medicaid services or auditing, to the following agencies: DMS, Kentucky Department of Education (KDE), Kentucky Department for Public Health, Centers for Medicare and Medicaid Services (CMS), any agency commissioned to audit this program and contractual third-party billing agents.

2.The school district cannot require you to pay anything towards the cost of your child’s health-related and/or special education services.

3.This will not affect your child’s available lifetime coverage or other Medicaid benefit; nor will it in any way limit your own family’s use of benefits outside of school. This will not affect your child’s special education services or IEP rights.; and it will not lead to any risk of losing eligibility for other Medicaid or DMS funded programs.

4.You have the right to change your mind and withdraw your permission at any time.
I give permission to the school district to share with DMS information concerning my child(ren) and their health-related services as necessary.I understand that this will help our school seek partial reimbursement of DMS covered services.
(14) Date

MonthDayYear
Date
Type your name below:
(3) Student First Name
(2) Student Last Name
(4) Student Date of Birth*

MonthDayYear
Date
Medicaid Number

Student Directory Information Notification

09.14 AP.12
Date

MonthDayYear
Date
Consistent with the Family Educational Rights and Privacy Act (FERPA), parents (or students 18 or older) may direct the District not to disclose directory information listed below. We are required to disclose a student’s name, address, and telephone number if listed at the request of Armed Forces recruiters and institutions of higher education, unless a parent or student who has reached age 18, requests that this information not be disclosed. Information about the living situation of a homeless student is not considered directory information.

Dear Parent/Eligible Student,

This letter informs you of your right to direct the District to withhold release of student directory information for students in the Madison County School District. Following is a list of items that the District considers student directory information. If you wish information to be withheld, please contact the school principal in writing specifying which directory information should not be released. The right to opt-out of directory information changes from parent to student upon the student;s eighteenth (18) birthday. Please be advised that parents cannot prevent the school from using directory information on District-issued ID cards or badges.

If we receive no response within thirty (30) days of the date of this letter, all student directory information will be subject to release without your consent. If you return a letter within the first thirty (30) days, we will withhold the directory information consistent with your written directions, unless disclosure is otherwise required or permitted by law. Once there has been an opt-out of directory information disclosure, the District will continue to honor that opt-out until the parent or the eligible student rescinds it, even after the student is no longer in attendance.

Directory information released to Third Parties other than Armed Forces Recruiters and Institutions of Higher Education

·         Student’s name

·         Student’s major field of study

·         Information about the student’s participation in officially recognized activities and sports

·         Student’s weight and height (if a member of an athletic team)

·         Student’s projected graduation date

·         Degrees, honors and awards the student has received

·         Student’s photograph/picture

·         Most recent educational institution attended by the student

·         Grade level

Armed Forces Recruiters & Institutions of Higher Education

(Parent or student who has reached age 18 may direct the District to withhold information in this section)

·         Student’s name

·         Student’s address

·         Student phone number

Sincerely,

School Principal

Review/Revised:4/14/2022

noreply@madison.kyschools.us
Hidden Field
MCS Enrollment
Hidden Field

ATTENTION PARENT/GUARDIAN:

Thank you for completing the enrollment packet. Please note you may be asked to provide additional required paperwork such as birth certificate, immunization certificate, physical & eye exam and proof of residency. Even though Madison County Virtual Academy students complete course work virtually, Madison County Schools are required to maintain the same cumulative records for them as students who attend in person.

Thank you for your cooperation.
Should be Empty:

Rows	Name (List only household members w/income, including students in home who have income)	Earnings from work before deductions	Weekly	Every 2 Weeks	Twice Monthly	Monthly	Public assistance, child support, alimony	Weekly	Every 2 Weeks	Twice Monthly	Monthly	Pensions, retirement, Social Security, SSI, VA benefits, All Other Income	Weekly	Every 2 Weeks	Twice Monthly	Monthly
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MADISON COUNTY SCHOOL DISTRICT STUDENT ENROLLMENT

Household Information

As a student of Madison County Schools, I understand and agree to follow the rules as stated in the Acceptable Use Policy above

Madison County Schools Transportation Verification Form

REGULATIONS FOR PUPILS RIDING MADISON COUNTY SCHOOL BUSES

For Middle School and High School Students Only:

For the Parent or Guardian:

Madison County Schools

Student Information (required):

Student Language Background (required):

Language for School Communication (not required):

Work Survey

Contact Information:

Kentucky Parental Notice for One Time Consent to Allow the School District to Access Kentucky Medicaid Benefits

Student Directory Information Notification

Consent for School Health Services

Child's Medical History

Child's Medical Insurance:

Consent for Health Services

Household and Income Form

HOUSEHOLD AND INCOME FORM

PART 2. HOMELESS, MIGRANT, RUNAWAY STATUS

Part 4. Signature

Rows	Names of all people living in your household (First, Middle Initial, Last)	School the child attends or indicate N/A if member is not in school	Grade Level	Check if a foster child (legal responsibility of the state welfare agency or court). If all children listed below are foster children, skip to Part 5 to sign this form.
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