ENROLLMENT FORM

ENROLLMENT FORM

2021 - 2022 ACADEMIC YEAR
Additional documents for registration

Bring this registration form and the following documentation to the school office.

• Original Certified Birth Certificate
• Current Immunization Form
• Copy of Parent ID or Student ID (if 18+ years old)
• Transcripts
• Other (i.e. copy of IEP services)
Student Information
Legal Full Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Gender *
Ethnicity *
How did you hear about our school? *
Home Phone Number *

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
CURRENT RESIDENCE ADDRESS *

Street Address

Street Address Line 2 (i.e. Apartment Number, Suite Number, P.O. Box)

City State / Province

Postal / Zip Code
Mailing Address (IF DIFFERENT THAN ABOVE)

Street Address

Street Address Line 2 (i.e. Apartment Number, Suite Number, P.O. Box)

City State / Province

Postal / Zip Code
Is the student living in someone else's home including living with other friend/family members, living at a shelter, at a hotel or motel, or in a vehicle? *
Is this the first school the student is attending in the state of California? *
List ALL high schools or middle schools previously attended
*
School Name & Grade Level Attended
School Name & Grade Level Attended
School Name & Grade Level Attended
Family Information
Parent/Guardian #1

Last Name First Name
Parent Phone Number (if different from above)
Please enter a valid phone number.
Parent #1 Email Address (Recommended)
Provide Parent Address (IF DIFFERENT THAN ABOVE)

Street Address

Street Address Line 2 (i.e. Apartment Number, Suite Number, P.O. Box)

City State / Province

Postal / Zip Code
Parent/Guardian #2

Last Name First Name
Parent Phone Number (IF DIFFERENT THAN ABOVE)
Please enter a valid phone number.
Parent #2 Email Address (RECOMMENDED)
example@example.com
Provide Parent Address (IF DIFFERENT THAN ABOVE)

Street Address

Street Address Line 2 (i.e. Apartment Number, Suite Number, P.O. Box)

City State / Province

Postal / Zip Code
Who has guardianship over student? *
Who has education rights over student? *
Are there any orders restricting the legal rights of either parent? *
(If you answered yes, please provide documents to the office)

Student Health Information
Does the student have a disability or special condition? *
If yes, please describe below:
Asthma? *

Yes, MILD Yes, MODERATE Yes, SEVERE No
Does the student carry an inhaler? (If yes, please provide documents to the office) *

Yes No
Allergies? *
If yes, please list ALL allergies down below:
Are there any activities which your child should not perform? *
(If yes, please provide documents to the office)
Is the student on prescribed medication? *
If yes, please list ALL prescribed medication and dosage down below:
Demographic Survey
Has the student previously attended New Village Girls Academy? *
Is student currently in foster care? *
If yes, please provide Notification of Placement Status Form/Agreement to the office
Is the student a resident Transitional Housing? *
Has the student's parent worked in one or more of the following industries in the last three years (agriculture, dairy, fishery, food processing/packing, or livestock)? *
Is either parent a service member of the military? *
Is either of the student's parents deceased? *
Is the student receiving counseling? *
If yes, please specify the provider down below:
Does the student have a social worker? *
If yes, please provide name and phone number down below:
Does the student have a probation officer? *
If yes, please provide name and phone number down below:
Is the student pregnant? *
Does the student have children? *
If yes, please provide the number of children down below:

Home Language Survey
What language did your daughter use when she first began to talk? *
What language does your daughter most frequently use at home? *
What language do you use most frequently to speak to your daughter? *
What language is most often spoken by the adults at home? *
If student is an English Language Learner, has she received any formal English language instruction (listening, speaking, reading, or writing)? *
Special Services
Did this student receive special education services at her previous school? *
Did this student have an Individualized Education Program (IEP) at her previous school? *
Did this student have a Section 504 Plan at her previous school? *
Does the student have difficulties that interfere with her ability to go to school or to learn? *
Has this student been identified for gifted and talented education services (GATE)? *
Is this student a member of the national honor Society? *

Parental Consent
Consent for Emergency Medical Treatment

As the parent or authorized representative, I hereby consent to New Village Girls Academy to obtain all emergency medical or dental care prescribed by duly licensed physician(M.D.), osteopath (D.O.), nurse practitioner, or dentist (D.D.S.) for my child. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of my child.
Consent for Emergency Medical Treatment *
If yes, please provide signature down below:
Parent/Guardian Signature:

Clear
Condom Availability Program

Public health statistics and reports indicate that increasing numbers of young people in their early teens are becoming involved in activities that put them at risk for infection. In addition, HIV/AIDS and sexually transmitted diseases are an epidemic in our community. Although the school does offer education which emphasizes abstinence as the only one hundred percent effective method of preventing infection, the District also realizes that not all students practice abstinence, and therefore should be instructed that condoms properly used to provide protection against sexual transmission of HIV/AIDS virus. In view of these facts, the California Board of Education enacted a law in 1992 to make condoms available for students unless parents contact the school in writing denying permission. Please note that if you do not wish your daughter to be able to obtain condoms through the school's Condom Availability Program, then you must submit a written letter to the school at any time.
Condom Availability Program *
If yes, please provide signature down below:
Parent/Guardian Signature:

Clear
Participation in the "Quiet Time" Transcendental Meditation Program in School:

I give consent for my child to take part in the Transcendental Meditation program at the school as part of "Quiet Time." I understand that Transcendental Meditation will be practiced twice daily in school on school days. Even though parent/guardian gives permission, participation in Meditation is optional. Student may choose to use this "Quiet Time" to simply rest. In addition, I give permission to obtain standard, simple health and medical information from my child which will be kept confidential.
Participation in the "Quiet Time" Transcendental Meditation Program in School: *
If yes, please provide signature down below:
Parent/Guardian Signature:

Clear
Parent Educational Level
Please check the statement that indicates the parent's educational level: *

Not a High School Graduate High School Graduate or Equivalent Some College (includes AA degree) College Graduate Graduate School/Postgraduate Training Decline to state or unknown
Parent/Guardian Signature

I verify that the information contained in this document is true and correct to the best of my knowledge.
Printed Parent/Guardian Name *

First Name Last Name
Parent/Guardian Signature *

Clear

New Village Girls Academy

"Media" Informed Consent and Release (Identity Specific, 2021-2022)
New Village Girls Academy frequently uses the photography and/or likeliness of a student or other member of a student family in brochures, press releases, video, newsletters, the New Village website, and other information or advertising media. In addition, news organizations may film or photograph students, and activities at New Village for use on television, websites or in print, for promotional, educational, or media purposes.

By signing this consent form, I hereby agree and give New Village or its authorized agents my permission, on behalf of myself and on behalf of any child I enroll at New Village, to record, film, photograph, audiotape, or videotape my or my child's image, photograph, likeliness, spoken words, student work, performance and movement, and/or voice (the "Information"). I understand that I may revoke my consent and release by providing a letter to the Principal at New Village at any time prior to the use of the Information.

By entering into this informed consent and release and granting the permission stated herein, I am expressly authorizing New Village to display, publish, distribute, exhibit or otherwise use, in whole or in part, in perpetuity the Information in all manner and media, as New Village determines in its sole discretion in connection with any material that may be created by New Village (including, without limitation, in advertising, publicizing and otherwise promoting New Village and its programs in brochures, press releases, video, newsletters, on the New Village website or for broadcasting on television. And for any purpose including, without limitation, providing information to prospective students, fundraising activities for New Village programs, grant funding applications, distribution at sponsorship events, and presenting to the news and publicity organizations for the purpose of promoting public awareness and support of New Village program.

I further agree that neither I nor my child will receive any compensation for such use of the Information from New Village or from any other source. By signing this I agree that I have been informed that my participation in any media event at New Village is strictly voluntary. I hereby agree that New Village is the sole owner of all rights, title, and interest, including copyrights in the use of the Information and any parts thereof for all purposes, as New Village shall determine in its sole discretion, without limitation, reservation or compensation to me or my child.

I hereby agree to release, defend, and hold harmless New Village from and against any claims, damages, or liability arising from or related to the use of the Information, including by not limited to any misuse, distortion, blurring, alteration, optical illusion or use in composite form, uploading onto websites, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction or production of the finished products its publication or distribution.
Student Name: *

First Name Last Name
Please check this box if you DO NOT give consent for any "Media" Release.
Parent/Guardian Signature *

Clear
New Village Girls Academy

Parent Permission Form for Learning Through Internships
Education at New Village is designed around student interests, and a big paart of this is our "Learning Through Internships" program. Every student is eligible for an internship, and we encourage all students to participate. They will receive a letter grade and elective credit.

Internships happen at a variety of sites in a wide range of career field. Past internship sites have included elementary school, pet rescues, law firms, hospitals, non-profits, photography and fashion studios and many more. Sites are always pre-screened by New Village staff, and all students will be mentored by a trusted professional with whom the school is in close contact.

A typical internship schedule will be Tuesday and Thursday, from 12:00 pm to 3:00 pm. When a match has been made, we will always provide you with all the information about the internship placement. In addition, you may call the school for further details.

Prior to securing an internship, students will complete workforce development and training in their advisories.

It is vital for us to have your support as a parent/guardian. Internships are a part of every student's education at New Village, and they may need help and encouragement to feel comfortable exploring their interests in a real-world setting.

Most students will get to their internship on the bus, with TAP cards provided by the school.

Parental/Guardian Consent

I have read the above explanation and understand that my child will be involved in off-site activities while enrolled at New Village. These will include interest visits with school staff, informational interviews with professionals, and regularly scheduled internships. I give permission for the student, named below, to participate in these individual and group activities as required and understand that the school’s insurance covers her at the work site but not during transportation to and from the school and the site. I will do my best to encourage and support her in the internship process.
Print Student Name: *

First Name Last Name
Print Parent/Guardian Name: *

First Name Last Name
Parent/Guardian Signature: *

Clear
New Village Girls Academy

Wellness Program
At New Village Girls Academy our vision is to equip girls with the skills necessary to live healthy and self-fulfilling lives. Through our Wellness Program, students will be empowered to make self-informed decisions about their physical, emotional, and social well being. We believe that personal health is at the cornerstone of academic success. As a result, New Village Girls Academy has developed a Women’s Wellness Program that can change behavior and outcomes by providing access to; individual and group mental health therapy, substance abuse support programs, clinic (medical) referrals, meditation twice a day, school-based women’s health & physical education workshops and school-wide monthly wellness days.

Topics/Themes of our Wellness Program
- Healthy Relationships
- Women’s Empowerment
- Gender Identities & LGBTQ issues
- Nutrition & Healthy Diets
- Physical Fitness
- Sex Education, Pregnancy Prevention & STDs
- Emotional Health & Tools for Mental Health
Physical and Emotional Support Services
- New Village will make medical appointments at partnering clinics upon student and/or guardian request. Parents or guardians will be informed of appointments if students are required to leave school during school hours.
- New Village will transport students to medical facilities in the event of an emergency in which a parent or guardian cannot be contacted.
- New Village will provide 1:1 and/or group counseling on campus to students who request those services and refer students to partner agencies for therapeutic services upon student and/or guardian request.
New Village Girls Academy will make the Wellness Program services available to all students free of charge to those who request them unless you, as the parent or guardian, withdraw permission by submitting a written letter to the school. By signing this form, you acknowledge that you have been informed of our programs.
Please check this box if you DO NOT give consent for any participation in the Wellness Program.
Parent/Guardian Signature *

Clear

STUDENT EMERGENCY CONTACT FORM

2021-2022 Academic Year
Student Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Date
Gender *
Grade Level *
Primary Language *
Student's Home Address *

Street Address

Street Address Line 2 (i.e. Apartment Number, Suite Number, P.O. Box)

City State / Province

Postal / Zip Code
Mailing Address (IF DIFFERENT THAN ABOVE)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian Name #1

First Name Middle Name Last Name
Cell Phone
Please enter a valid phone number.
I authorize receiving text messages and understand that I am responsible for all text related charges.
Work Phone
Please enter a valid phone number.
Email Address (RECOMMENDED)
example@example.com
Parent/Guardian Name #2

First Name Middle Name Last Name
Cell Phone
Please enter a valid phone number.
I authorize receiving text messages and understand that I am responsible for all text related charges.
Work Phone
Please enter a valid phone number.
Email Address (RECOMMENDED)
example@example.com
In case you are unable to reach me during an emergency, you are authorized to contact and, if necessary, release my child to the following:
EMERGENCY CONTACT #1 *

First & Last Name RELATIONSHIP TO STUDENT
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
EMERGENCY CONTACT #2 *

First & Last Name RELATIONSHIP TO STUDENT
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
EMERGENCY CONTACT #3

First & Last Name RELATIONSHIP TO STUDENT
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
HEALTH ALERTS -- List any medical condition(s) which restricts physical activity or requires special attention. Include conditions (i.e. asthma, seizures) and/or allergies (i.e. peanuts and bee stings). If none, please type “NONE.”
My child is ALLERGIC to the following medications: *
My child CURRENTLY TAKES the following medications: *
*

I CERTIFY THAT I HAVE READ AND UNDERSTOOD THIS FORM AND DO HEREBY GIVE MY AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT, AND THAT ALL OF THE INFORMATION I HAVE PROVIDED ON THIS FORM IS TRUE AND CORRECT.
Parent/Guardian Signature *

Clear
Should be Empty:

ENROLLMENT FORM

Student Information

List ALL high schools or middle schools previously attended

Family Information

Student Health Information

Demographic Survey

Home Language Survey

Special Services

Parental Consent

Consent for Emergency Medical Treatment

Condom Availability Program

Participation in the "Quiet Time" Transcendental Meditation Program in School:

Parent Educational Level

Parent/Guardian Signature

New Village Girls Academy

New Village Girls Academy

New Village Girls Academy

STUDENT EMERGENCY CONTACT FORM

HEALTH ALERTS -- List any medical condition(s) which restricts physical activity or requires special attention. Include conditions (i.e. asthma, seizures) and/or allergies (i.e. peanuts and bee stings). If none, please type “NONE.”