Millennium Community School Enrollment Application v2

Millennium Community School Enrollment Packet
-Please Read Carefully-

This application is for the 26-27 school year.

The primary guardian will contacted once the application has been submitted and processed.

Thank you!

ENROLLMENT CANNOT BE PROCESSED OR FINALIZED UNTIL THE PACKET IS COMPLETE. INCOMPLETE SUBMISSIONS MAY RESULT IN DELAYS.

EFFECTIVE DECEMBER 19, 2025, HOUSE BILL 114 HAS BEEN SIGNED INTO LAW, IT MODIFIES THE AGE REQUIREMENTS FOR KINDERGARTEN ADMISSION, STIPULATING THAT SCHOOL DISTRICTS MUST ADMIT STUDENTS WHO ARE FIVE YEARS OLD BY THE FIRST DAY OF INSTRUCTION IN THE SCHOOL YEAR OF ADMITTANCE.
PLEASE ENSURE THAT ALL SECTIONS OF THE ENROLLMENT PACKET ARE FULLY COMPLETED AND THAT ALL REQUIRED DOCUMENTS ARE SUBMITTED AT THE SAME TIME. ENROLLMENT CANNOT BE PROCESSED OR FINALIZED UNTIL THE PACKET IS COMPLETE. INCOMPLETE SUBMISSIONS MAY RESULT IN DELAYS. EFFECTIVE DECEMBER 19, 2025, HOUSE BILL 114 HAS BEEN SIGNED INTO LAW, IT MODIFIES THE AGE REQUIREMENTS FOR KINDERGARTEN ADMISSION, STIPULATING THAT SCHOOL DISTRICTS MUST ADMIT STUDENTS WHO ARE FIVE YEARS OLD BY THE FIRST DAY OF INSTRUCTION IN THE SCHOOL YEAR OF ADMITTANCE.
** If you are not the leaseholder of your residence, you must submit a Residency Affidavit.

Millennium Community School is committed to the concept of an open-door policy and equal educational opportunity. in accordance with federal/state law and school policy, Millennium Community School does not discriminate in any of its policies, procedures or practices on the basis of age, color, sex, religion, national origin, race, creed, or disabilities.

PLEASE RETURN DURING OFFICE HOURS: 8:00 Α.Μ. – 3:15 P.M. & 4:00 Ρ.Μ. – 5:00 Ρ.Μ.

STATE TESTING AND COMPULSORY ATTENDANCE NOTIFICATION TO PARENTS
Dear Parent/Guardian:

Millennium Community School is a community school established under Chapter
3314 of the Ohio Revised Code.

As a public school, enrolled students are required to take Proficiency Tests and
other examinations prescribed by law. In addition, there may be other requirements
for students at the school that are prescribed by law.

Students who have been excused from compulsory attending law for the purpose of
home education as defined by the Administrative Code shall no longer be excused
for that purpose upon their enrollment in the community school.

To see a copy of Millennium's previous years state test results, please visit the Ohio
Department of Education website or obtain a copy from the school's main office.

For more information about this matter, please contact the school at (614) 255-
5585 or the Ohio Department of Education.

Sincerely,

Tijuana Russell
School Director

REQUEST FOR RELEASE OF STUDENT RECORDS
PREVIOUS SCHOOL INFORMATION
PREVIOUS SCHOOL NAME:
STREET ADDRESS:
CITY, STATE & ZIP CODE:
PHONE NUMBER:
Format: (000) 000-0000.
FAX NUMBER:
Format: (000) 000-0000.
STUDENT INFORMATION
Name

First NameMiddle NameLast Name
BIRTH DATE:

MonthDayYear
Date
UPCOMING GRADE LEVEL:
ENROLLMENT DATE:

MonthDayYear
Date
The records to be released should include:
- Discipline Records/Reports
- All Report Cards/Progress Reports
- Results of all standardized tests (OAA) and evaluations
- Results of all Cognitive Abilities test and evaluations
- Results of all criterion-referenced tests and evaluations
- Current Health Card/Shot Records
- All Student Study Team (SST) evaluations and recommendations
- All Special Education Records including current ETR evaluations and Individual Education Program (IEP)
- Third Grade Guarantee results
Please send all information to:
Millennium Community School
3500 Refugee Road
Columbus, Ohio 43232
OR Fax to: (614) 255-5580
Parent/Guardian Signature:

PREVIOUS SCHOOL INFORMATION
School District of Residence:
Public SchoolCharter SchoolHome SchoolNonpublic
Previous School Name:
Previous School Address:
Previous Grade:
Withdrawal Date from Previous School:
Was your child suspended, expelled or under a discipline plan at the previous school attended?

YESNO
If YES, please explain:
INCOMING KINDERGARTEN STUDENTS ONLY
Was your child enrolled in pre-school?

YESNO
Pre-school Name:
Pre-school Address:
Phone Number:
Format: (000) 000-0000.
Part-Time or Full-Time Status
INFORMATION VERIFICATION
Due to the Missing Child Law (O.R.C. Sec 3313.672), a copy of every student's birth certificate or other acceptable substitute must be on file. If documentation is not presented within 14 days of enrollment, we are required by law to notify our local law enforcement agency. This is for the protection of your child. If this student is court placed into the care of a legal guardian, a copy of the court document must accompany this enrollment application and is good for only one (1) school year or the terms of the court papers or if address changes, whichever comes first. If a divorce situation exists, certified full copy of the order or decree is required. Only court ordered custody documents are accepted.

I certify that the above stated information is correct and further understand that parts of it will be used to retrieve a Statewide Student Identification Number required by House Bill 282 for my student

I state that the information provided is true and correct. I am aware that the Millennium Community School may use any legal means to verify my residence. I understand that falsification of information may be cause for immediate withdrawal of my student from the Millennium Community School and subject me to applicable criminal and civil penalties
Parent/Guardian Signature:

EMERGENCY CONTACT INFORMATION
Emergency Contact #1:
Name

First NameMiddle InitialLast Name
Home Address:

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone:
Format: (000) 000-0000.
Cell Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
Relationship to Student:
Emergency Contact #2:
Name

First NameMiddle InitialLast Name
Home Address:

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone:
Format: (000) 000-0000.
Cell Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
Relationship to Student:
Emergency Contact #3:
Name

First NameMiddle InitialLast Name
Home Address:

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone:
Format: (000) 000-0000.
Cell Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
Relationship to Student:
Emergency Contact #4:
Name

First NameMiddle InitialLast Name
Home Address:

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone:
Format: (000) 000-0000.
Cell Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
Relationship to Student:

STUDENT MEDICAL INFORMATION

Important information obtained from this health history will be included on a confidential health condition list, if appropriate.
Student Name:
Date of Birth:

MonthDayYear
Date
Students Grade
Home Address:

Street Address

Street Address Line 2

CityState

Zip Code
ALLERGIES - Please list and describe all allergens and reactions to:
Recommended treatment for allergic reactions:
HEALTH CONDITIONS - Please list all health conditions:
MEDICATIONS - Please indicate all medications prescribed:
NOTE: If your child requires medication at school, then all medication sent to the school must be in the original prescription container with a current date AND an 'Authorization for Administration of Medication' form must be on file (obtain from the front desk).
Parent/Guardian Signature:
EMERGENCY INSTRUCTIONS

I give permission to Millennium Community School to secure emergency medical and/or surgical treatment for the above-named minor child while in its care.I do NOT give permission to Millennium Community School to secure emergency medical and/or surgical treatment for the above-named minor child while in its care.
Physician's Name:
Phone Number:
Format: (000) 000-0000.
Physician's Address:

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Signature:

MILLENNIUM COMMUNITY SCHOOL POLICIES
DRESS CODE POLICY
1. Arrive and leave school in dress code attire. Dress code attire consists of:
- LIGHT BLUE oxford shirts or polos. (Logo is optional) Shirts are to be tucked in and always buttoned completely.
- NAVY BLUE uniform pants/skirts/shorts/jumpers/skorts. Jeans (of any color), sweatpants, or athletic pants are not permitted. Pants with holes, tears or rips are not permissible.
- Clothing should cover from the shoulders to three inches above the knee. Pictures, patches and wording on clothing are not permitted. NO SAGGING! Belts (black or brown only) must be worn!
- BLACK SHOES (must be 75% black with no other color, design or metal) should be comfortable that will allow students to always be safe. Closed toe and less than 1" heel. Wedges, sandals, flip-flops, athletic slip-ons, Heelys or Crocs are not permitted.
- NAVY BLUE or WHITE stockings, tights or socks ONLY (no other colors). No leggings or jeggings are permitted.
- Accessories are limited to the following: one watch and small post (stud-style) earrings. Students hair accessories (beads, ballies, headbands, barrettes and/or ribbons) should be clear, white, light blue or navy blue. Hair color must stay within the normal/natural range of colors (blonde, brown, black or red) and should be styled in a manner that does not draw excessive attention. Hats, bandanas, skull caps, etc. of any type are not to be worn in the building or at school-related events. Pictures, patches or wording on clothing is not permitted.
2. Dress code Infraction Enforcement:

If your student is in violation of the dress code policy, they will be sent to the office. Administration reserves the right to require the parent/guardian to pick up your child or bring proper clothing in accordance with the dress code to change at school. Administration also reserves the right to refer your child to the nurse's office to change if sizes are available.
Suspensions can occur if your child violates the dress code policy after the initial warning.

3. Appearance must be clean, neat and well-groomed each day.
VISTOR POLICY
Visitors are always welcome. Visitors must first report to the front office, and provide a valid state issued I.D. to a front desk team member. All visitors will be verified via the Raptor Technology system, and a guest badge will be produced that must be worn for the duration of the visit. Visitors are not permitted to interrupt teachers during instructional time. Please set up an appointment with your students' teacher for questions and/or concerns regarding your students.
STUDENT RELEASE POLICY – PHOTO IDENTIFICATION REQUIRED
Students cannot be released from the classroom at any time without an authorization from the front office. You must be at least 18 years of age to pick up a student
STUDENT BEHAVIOR POLICY
Millennium Community School has zero tolerance for fighting and excessive student misconduct. If your student is fighting, they will be suspended for a minimum of 10 days. If your student is removed from the classroom and sent to the office, you will receive a phone call and may be asked to pick up your child.
My signature below indicates that I have read DRESS CODE POLICY, VISITOR POLICY, STUDENT RELEASE POLICY AND STUDENT BEHAVIOR POLICY. I agree with the terms stated within the above policies. I certify that the information contained in this application is true and complete and that false information may forfeit enrollment at Millennium Community School.
Parent/Guardian Name (please print):
Student Name (please print):
Parent/Guardian Signature:

FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT (FERPA)
Family Educational Rights and Privacy Act of 1974, also known as FERPA, was established to protect the privacy of students' education records. Under the Act, the Millennium Community School cannot make public any student records without the consent of the parent(s)/legal guardian(s). It is the practice of the Millennium Community School, NOT to release any personal student information or Directory Information* to the public. Directory Information is intended solely for school use by the Millennium Community School and Staff and will not be distributed to any person(s) or organization(s).

The Millennium Community School requests all parent(s)/guardian(s) to complete the below acknowledgement and consent form and should be returned to the Parent Liaison/Parent Liaison Assistant no later than September 30th of each school year. If the form is not completed and returned as requested, the Millennium Community School will assume that the parent(s)/guardian(s) does not wish to have their child's Directory Information released to the public.

*Directory Information is defined by FERPA as: The student's name, address and telephone number; student's participation in recognized activities and sports; weight and height of members of athletic teams; dates of attendance; degree and awards received; and most recently attended school.

I hereby request Millennium Community School and their representatives to make available my student's Directory Information to any person(s) or organization(s), unless prior written consent is given.
Parent/Guardian Name (please print):
Student Name (please print):
Parent/Guardian Signature:
MEDIA/INTERVIEW/PHOTO RELEASE FORM
Please check the items you would like to allow your child to participate in and sign below:

NEWS INFORMATION RELEASE - There may be times during the school year when the school, news media or others with to photograph or videotape your child at Millennium Community School for use in print, video, internet or other communication methods. I give my permission to Millennium Community School to provide information concerning school activities with my child to the general news media I also give my permission for my child's name, portrait, picture or voice to be used for display or in promotional material in a variety of mediums for the school and/or in local media coverage of school events.COMMUNICATION RELEASE - There may be times during the school year when the school or others wish to identify your student by name and grade in newsletters, publications or yearbooks. I give my permission to Millennium Community School and its sponsor, to identify my child by name and grade in newsletters, publications and yearbooks.ARTWORK RELEASE - There may be times during the school year when the school, sponsor, news media, or others wish to use artwork created by your child at the school for use in print, video, internet or other communication methods. I give my permission to Millennium Community School to provide information concerning school activities with my child to the general news media. I also give my permission for my child's name, portrait, picture or voice to be used (both now and in the future) for display or in promotional material in a variety of mediums for the school or its sponsor and/or in local media coverage of school events. I agree to participate in these projects without financial remuneration, and I understand that this releases Millennium Community School from any future claims as well as from any liability arising from the use of said items/materials.
I acknowledge that subsequent to the date my child ceases to be enrolled at Millennium Community School, I may revoke the forgoing grant of permission by providing Millennium Community School, with specific written notice of such revocation.
Parent/Guardian Name (please print):
Student Name (please print):
Parent/Guardian Signature:

INTERNET ACCEPTABLE USE POLICY
The use of technology and computer resources at Millennium Community School is a revocable privilege. Failure to abide by this policy may render you ineligible to use Millennium Community School's computer facilities and may bring additional disciplinary action.

All users are expected to use the technology available at Millennium Community School in a manner appropriate to Millennium Community School's academic and moral goals. Technology includes, but is not limited to, cellular telephones, beepers, pagers, radios, CD/MP3/DVD players, video recorders, video games, personal data devices, computers, other hardware, electronic devices, software, Internet, email and all other similar networks and devices. Users are expected to be responsible and use technology to which they have access appropriately. Obscene, pornographic, threatening or other inappropriate use of technology including, but not limited to, email, instant messaging, web pages and the use of hardware and/or software which disrupts or interferes with the safety and welfare of Millennium Community School is prohibited, even if such uses take place after school or off Millennium Community School property.

Failure to adhere to this policy and the guidelines below will result in disciplinary action as outlined in the Student Code of Conduct. Found in Student/Parent/Teacher Handbook.
Parent/Guardian Name (please print):

First NameLast Name
Student Name (please print):

First NameLast Name
Parent/Guardian Signature:
CELL PHONE POLICY
PHONES ARE NOT TO BE USED DURING SCHOOL. Every student will be assigned a personal Yondr Pouch. While the Yondr Pouch is considered school property, it is each student's responsibility to keep it in good working condition and return the pouch to designated areas during dismissal daily.
DAILY PROCESS
As students ARRIVE TO SCHOOL, they will:
1. Turn their phone off.
2. When students arrive to class, place their phone inside their Pouch and secure it in front of school staff.
3. Store their Pouch in their backpack OR locker for the day.
At the end of the day, students will proceed to their designated dismissal area, where a staff member will open their Pouch and return the device(s) to the student. The Pouches will be returned to homeroom teachers for distribution the following day.
** Students leaving early will be able to unlock their Pouch at the Front Office.
** Students with health complications will receive and return a Velcro version of the Yondr pouch.
VIOLATIONS
POUCH DAMAGE/LOST POUCH/USING OR HAVING PHONE DURING SCHOOL

1. If a student damages their Pouch, Administration will collect the phone/Pouch and call home for:
- Parent Pickup of device
- $50.00 fee for a replacement Pouch
- 3-day suspension
2. If a student is caught on their phone during restricted hours without permission, Administration will collect the phone for:
- Parent Pickup of device
- 2 days of after school detention
EXAMPLES OF DAMAGE:
❖ Deep scratches on the globe and on the green ring around it
❖ Intentional pen marks on the inside of the pouch
❖ Bent pins
❖ Pin and button not fully recessing, due to pin damage
Parent/Guardian Name (please print):

First NameLast Name
Student Name (please print):

First NameLast Name
Parent/Guardian Signature:

SCHOOL-PARENT-STUDENT-TEACHER CONTRACT OF AGREEMENT

Your signature in the appropriate area below signifies your commitment to help fulfill the Millennium Community School's Mission to provide a disciplined, nurturing and safe environment that is conducive to academic success.
As a STUDENT at the Millennium Community School, I pledge to:
- Attend school regularly and on time.
- Work towards success in school by having high expectations for myself
- Complete and return assignments and homework on time.
- Follow the dress code.
- Accept responsibility for all actions.
- Follow school rules for conduct to ensure the safety of myself and my fellow students.
- If I follow these rules, I will be able to engage in various incentives and will be able to continue to be educated at Millennium Community School. Failure to follow the rules may result in the loss of various privileges, suspension and/or expulsion from Millennium Community School.
Student Signature:
As a PARENT(s)/GUARDIAN(s) of
I/we pledge to:
- Ensure my child is well rested and at school by 8:30 a.m. each day.
- Maintain high expectations for my child and Millennium Community School.
- Demonstrate consistent interest in my child's progress at Millennium Community School.
- Support school goals by providing a consistent place and time for homework and verifying completion.
- Adhere to the provisions outlined in the PARENT AND STUDENT HANDBOOK.
- Attend scheduled parent/teacher conferences.
- Volunteer for school activities whenever possible.
- Ensure that my child adheres to the dress code.
- I/we also understand that my child must follow the rules set forth at the Millennium Community School to ensure the safety, interest and rights of all protected. To further strengthen this quality, I/we will model the appropriate behavior at home.
- I/we understand that if my child follows these rules, he/she will be able to engage in various incentives and will be able to continue to be educated at Millennium Community School.
- Failure to follow the rules may result in the loss of various privileges, suspension and/or expulsion from Millennium Community School.
Parent/Guardian Signature:
TEACHER PLEDGE
As a TEACHER at the Millennium Community School, I pledge to:
- Help each student reach his/her fullest potential.
- Communicate and work with families on a consistent basis to support student learning.
- Provide high quality instruction in a supportive learning environment.
- Treat students, parents and co-workers with dignity and respect
- Communicate classroom rules and consequences to parents and students.
ADMINISTRATOR PLEDGE
As an ADMINISTRATOR, I pledge to:
- Create an environment that encourages and welcomes parental involvement, and positive communication between teacher, parent and the student.
- Provide an educational environment that enhances learning and provides teacher accountability.
- We promise to support each other and carry out the terms of this agreement

AFTER SCHOOL STUDENT TRANSPORTATION FORM
To help ensure the safety of your child, please complete the following information
STUDENT NAME:
GRADE:
My student will be traveling home by:

DAYCARE PROVIDERWALKER/PICK-UP STUDENTBUS RIDER
DAY CARE PROVIDER
Name:
Address:
Contact Person:
Phone:
Format: (000) 000-0000.
WALKER/PICK-UP STUDENT

My student will be walking home from school.My student will be picked up by a trusted adult from school.
BUS RIDER
DISTRICT RESPONSIBLE FOR TRANSPORTATION:
APPROVED ADULTS FOR STUDENT PICK-UP
THE PARENT OR LEGAL GUARDIAN MUST CONTACT THE OFFICE BEFORE ANY STUDENT IS RELEASED TO A DIFFERENT ADULT. ALL ADULTS PICKING UP A STUDENT MUST PROVIDE A STATE ISSUED I.D. IN ORDER TO PICK UP STUDENTS
1.
2.
3.
4.
5.
My child will be traveling home in the way stated above. I understand that I will send a written notification or call into the office at Millennium Community School should I wish to change my student's dismissal procedure.
Parent/Guardian Signature:

Birth Certificate

Cancelof
Social Security Card

Cancelof
Immunization Records

Cancelof
Valid Parent/Guardian Driver's License

Cancelof
Current Lease Agreement, Deed or Mortgage Statement

Cancelof
One of the following (DATED WITHIN 30 DAYS OF JULY): Utility Bill (gas, electric or water, Paycheck Stub, Bank Statement, Ohio Human Services Paperwork or Social Security Paperwork

Cancelof
Most Recent Report Card

Cancelof
Proof of TB test for any student who was born or lived outside the United States (if applicable)

Cancelof
If Student is Special Needs, all Special Education Records, including current IEP/ETR paperwork

Cancelof
Should be Empty:

Millennium Community School Enrollment Packet

STATE TESTING AND COMPULSORY ATTENDANCE NOTIFICATION TO PARENTS

REQUEST FOR RELEASE OF STUDENT RECORDS

PREVIOUS SCHOOL INFORMATION

STUDENT INFORMATION

STUDENT INFORMATION

RESIDENTIAL PARENT/ GUARDIAN 1 CONTACT INFORMATION

RESIDENTIAL PARENT/ GUARDIAN 2 CONTACT INFORMATION

PARENT/GUARDIAN DEMOGRAPHICS

SIBLING INFORMATION

ETR/IEP SERVICES

PREVIOUS SCHOOL INFORMATION

INCOMING KINDERGARTEN STUDENTS ONLY

INFORMATION VERIFICATION

EMERGENCY CONTACT INFORMATION

Emergency Contact #1:

Emergency Contact #2:

Emergency Contact #3:

Emergency Contact #4:

STUDENT MEDICAL INFORMATION

MILLENNIUM COMMUNITY SCHOOL POLICIES

DRESS CODE POLICY

VISTOR POLICY

STUDENT RELEASE POLICY – PHOTO IDENTIFICATION REQUIRED

STUDENT BEHAVIOR POLICY

FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT (FERPA)

MEDIA/INTERVIEW/PHOTO RELEASE FORM

INTERNET ACCEPTABLE USE POLICY

CELL PHONE POLICY

DAILY PROCESS

VIOLATIONS

SCHOOL-PARENT-STUDENT-TEACHER CONTRACT OF AGREEMENT

TEACHER PLEDGE

ADMINISTRATOR PLEDGE

AFTER SCHOOL STUDENT TRANSPORTATION FORM

DAY CARE PROVIDER

BUS RIDER

APPROVED ADULTS FOR STUDENT PICK-UP