Washington Virtual Academies 2601 S 35

Th St, Suite 100

Tacoma, WA 98409

Ph: 866-467-6187

Fx: 253-295-4798

2013/2014 School Year Enrollment Forms Fax Cover Sheet

Please review the information below. Based on your student(s) grade and applicable circumstances, you are required to submit documentation in order to complete this step in the enrollment process. You can fax, scan and email, or mail the required paperwork. Important Note: Please send copies; do not mail the original documents. Fax (preferred): 1-253-295-4798 Scan and Email: wavafax@k12.com Mail: Washington Virtual Academies 2601 S 35th Street, Suite 100

**All Students 18 Years and Older Must Sign ALL Enrollment Paperwork** Tacoma, WA 98409 Student Name: ______________________________________________________________________________________________________

Parent/Guardian Name: _______________________________________________________________________________________________

Number of pages including cover sheet: ___________ Date: ___________

New Student Enrollment Forms Checklist (Please check each form you are including in your fax)

Birth Certificate (if enrolling in Kindergarten)

Certificate of Immunizations-Be sure to sign this form in the top Right Corner or the form will be Rejected, (please make sure Immunizations are transcribed

onto the WA State form provided, parents are required to send this in at the time of enrollment)

Proof of Residence (utility bill, if living with family, friends, or any other circumstances please include a letter stating you and your family are residing at

their residence and a copy of their utility bill or signed Lease/Rental Agreement)

13/14 Inter District/Choice Release Registration Form

Release of Student Records (this form is to be sent directly to WAVA and not turned into your resident school/school district, WAVA will send upon

approval)

9Th Grade students most recent Report Card or Progress Report

10th-12Th Grade students Unofficial or Official transcript

If your student has a 504 Plan, please submit a copy

If your student has an IEP, WAVA will request a copy

If you have indicated you have a Parenting Plan or Restraining order, Please submit a copy

Re-Enrolling Student Enrollment Forms Checklist (Please check each form you are including in your fax)

Proof of Residence if you have moved

If your student is entering the 6Th grade please provide the date for the Tdap Booster Immunization (this is required to enter the 6th grade)

13/14 Inter District/Choice Release Registration Form

If you have indicated you have a Parenting Plan or Restraining order, Please submit a copy

2013/2014 New Student Registration Form Washington Virtual Academies Enrollment Processing Center

2601 South 35th Street, Ste 100 Tacoma, WA 98409

WAVA Monroe WAVA Omak Grades K-8 Grades 9-12 Phone: 1-866-467-6187 Fax: 1-253-295-4798 www.wava.org

Student Name First Middle Legal Last Name (as appears on Birth Certificate) Last Name also known as: Birthdate Grade Entering Phone Number

Statement of Understanding

In accordance with the Alternative Learning Experience Implementation Standards, reference WAC 392-121-182 (3)(e), prior to enrollment parent(s) or guardians shall be provided with, and sign, documentation attesting to the understanding of the difference between home-based instruction an enrollment in an alternative learning experience (ALE). Home-Based Instruction (Home School not using WAVA Program

Is provided by the parent or guardian as authorized under RCW 28A.200 and 28A.225.010. Students are not enrolled in Public Education. Students are not subject to the rules and regulations governing public schools, including

course, graduation, and assessment requirements. The public school is under no obligation to provide instruction or instructional materials, or

otherwise supervise the student’s education.

Alternative Learning Experience-Washington Virtual Academies

Is authorized under WAC 392-121-182. Students are enrolled in public education either full time or part time. Students are subject to the rules and regulations governing public school students including course, graduation, and

assessment requirements for all portions of the ALE. Learning experiences are:

Supervised, monitored, assessed, and evaluated by certified staff. Provided via a written student learning plan. Provided in whole, or part outside the regular classroom.

Part –time Enrollment of Home-Based Instruction Students

Home-based instruction students may enroll in public school programs, including ALE programs, on a part-time basis and retain their home-based instruction status. In the case of part-time enrollment in ALE, the student will need to comply with the requirements of the ALE written student learning plan, but not be required to participate in state assessments or meet state graduation requirements. *Please note Part-Time Enrollment of Home-Based Instruction is aside from Washington Virtual Academies as we are an ALE Program and a Public School.*

I have read the descriptions of home-based instruction and alternative learning experiences provided and understand the difference between home-based instruction and the alternative learning experience

program in which my child is enrolling. Parent/Guardian/Student Signature: _______________________________________________________________________________________________________________________ Date_____________________

**All Students 18 Years and Older Must Sign ALL Enrollment Paperwork**

Ethnicity and Race Data Collection

Question 1 Is your child of Hispanic or Latino origin? (Check all that apply) Mexican/Mexican American/Chicano Not Hispanic/Latino Cuban Central American Dominican Latin American Puerto Rican Other/Hispanic/Latino Spaniard South America Question 2 What race(s) do you consider your child? (Check all that apply) African American/Black Indonesian Taiwanese Guamanian or Chamorro Alaska Native Makah Pakistani Lummi

White Japanese Thai Mariana Islander Chehalis Muckleshoot Squaxin Island Yakama

Asian Indian Korean Vietnamese Melanesian Nooksack Nisqually HOH

Chinese Laotian Other Asian Samoan Native Hawaiian Spokane Stillaguamish

Sohal Water Snoqualmie Sauk-Suiattle Tongan Cowlitz Puyallup Jamestown

Filipino Malaysian Colville Samish Quinalut Port Gamble Klallam Suquamish

Hmong Singaporean Fijian Kalispel Lower Elwha Quileute Tulalip

Legal Parent/Guardian Signature _______________________________________________________________________________________________ Date ___________ **All Students 18 Years and Older Must Sign ALL Enrollment Paperwork**

DISCIPLINE INFORMATION (please check your answers)

Has your child ever been suspended? YES NO If Yes, Why: ____________________________________________________________________________________ Has your child ever been Expelled? YES NO If Yes, Why: ____________________________________________________________________________________ Is your student currently under a suspension, expulsion, or Becca Bill/Truancy Petition? YES NO If yes, Name of School: __________________________________________________________________ If Suspended or Expelled, Why: _________________________________________________________

CUSTODY INFORMATION (please check your answers)

Who is the primary custodial parent? ____________________________________________________________ Is there a joint custody or parenting plan in effect? YES NO Is there a restraining order in effect? YES NO Restraining order is against? Mother Father Other: _________________________________________ Begin Date: ______________________ Exp Date: ________________

*Please note if there is a restraining order or parenting plan in affect you will need to send in a copy prior

to students enrollment approval.*

                                                 2013/2014 Inter‐District/Choice Release Registration Form             Washington Virtual Academies  Enrollment Processing Center

2601 South 35th Street, Ste 100 Tacoma, WA 98409

WAVA Monroe WAVA Omak Grades K-8 Grades 9-12                                                                          Phone: 1‐866‐467‐6187              Fax: 1‐253-295-4798                                           www.wava.org  

 

Student Name First Middle Legal Last Name (as appears on Birth Certificate) Last Name also known as: Birthdate Grade Entering Phone Number

______________________________________________________________________________________ Name of Resident School District: __________________________________________________________________  

Physical Street Address City Zip Code Name of Current School: _________________________________________________________________________

State the reason(s) why the transfer is requested: _________________________________________________________________________________________________________________________________________________

Is your student currently enrolled in a special program: Yes No If yes, please check all that apply. TITLE 1/Chapter 1 IEP/Special Education GIFTED ESL/ELL/ESL Services/ELL Plan 504

Is the IEP Current? Yes No IEP Date: __________________ Evaluation Date: __________________ Is the 504 Current? Yes No Date: __________________

What is the primary language in the home? ____________________________ Is your child's first language a language other than English? YES NO If yes, what language? ______________________

My student is Special Education and will be receiving all Special Education Services and associated courses at___________________________________________________, in the______________________________________ School District.

How will you be enrolling your student with Washington Virtual Academies? (Choose ONE of the options below) My student will attend Washington Virtual Academies Full Time 1.0 FTE

Kindergarten Grades 1-8 Grades 9-12 (please fill in courses)

My student will attend Washington Virtual Academies Part Time and claim Part Time Home School status. By choosing this option you must sign the Intent to Provide Home School Instruction below.

Declaration of Intent to Provide Home School Instruction Note: Washington Virtual Academies is a Public School A Parent who intends to cause his/her child or children to receive home school instruction in lieu of attendance or enrollment in a public school, approved private school, or an extension program of an approved private school must file an annual declaration of intent to do so in the format prescribed below: I do hereby declare that I am the parent, guardian, or legal custodian of the child listed below; that said child is between 5 and 17 and as such are subject to the requirements found in chapter 28A.225 RCW Compulsory Attendance; I intend to cause said child to receive home school instruction as specified in RCW 28A.225.010(4); and if a certificated person will be supervising the instruction, I have indicated this by checking the appropriate space.

X Parent/Guardian/Student Printed Name & Signature Date

My student will attend both Washington Virtual Academies and (name of school) ___________________________________________, in the________________________________________ School District. The Washington Virtual Academies (WAVA) is an Alternative Learning Experience (ALE). The above named student is enrolled in your district and would like to exercise his/her option to take some courses through WAVA RCW 28A.225.220). According to WAC 392-121-188, school districts have the authority to enter into Inter-district cooperative agrees with other school districts under RCW 28A.225.250. Please complete the form below to ensure our district under RCW 28A.225.250. Any student enrolled in WAVA with a .60 FTE or higher, WAVA will be responsible for the student(s) testing. Any student attending the RSD with a FTE of .60 or higher, the RSD will be responsible for the student(s) testing.

Parent/Guardian Name & Signature_______________________________________________________________________________________________________________________Date:_______________

Enrollment Acceptance/Denial Signature Resident District Signature ___________________________________________________________________________________________ Approved Denied FTE:_________ Date: ____________ Non-Resident District Signature________________________________________________________________________________________ Approved Denied FTE:_________ Date: ___________

Math/Language Arts

Science

Math Language Arts

Science

History/Art PE

WAVA Courses Home School Courses (these courses will be independently instructed)

Total FTE: ________________ Total FTE: ________________

Resident School Courses FTE WAVA/Omak HS Courses (.20 FTE per WAVA Course) FTE WAVA K8 Courses (.25 per WAVA Course) FTE

Total FTE: ________________ Total FTE: ________________ Total FTE: ________________

1.)

2.)

3.)

Washington Virtual Academies Enrollment Processing Center 

2601 South 35th Street, Ste 100 Tacoma, WA 98409 Ph. 1.866.467.6187 Fx. 1. 253-295-4798 

www.k12.com/wava 

Release of Student Records Please accept this document as formal approval for the release of all official school records (including the record of transcripts, testing information, special education, 

health and immunization records).  Please do not send any records unless this form has been sent to you directly by a Washington Virtual Academies school official. 

Student Information 

Student’s Full Name: _____________________________________________________________________________________________________________________                    First                                                                 Middle                                                        Legal Last                                                              Also known as: 

 Student’s Date of Birth: ________________________________                                                                                              Home Phone: ____________________________  Student’s Legal Address: __________________________________________________________________________________________________________________ 

                          Street                                                                                                                                                                         Apt #  _______________________________________________________________________________________________________________________________________ City                                                                                 County                                                                           State                                                                    Zip Code  

Homeschooled or Never Previously Enrolled in School (fill out only if applicable) Check Below if Applicable: 

 □ Student was always previously homeschooled   □ Student is enrolling in Kindergarten □ Has your student ever attended a public school, private school, home school program, or any other accreditated program during his/her education time 

period?  Yes __ No___ If yes, please complete below portion.  

Prior School Information  

Current School of Attendance: ____________________________________________________________________________________________________  School Address: _________________________________________________________________________________________________________________________                               Street _______________________________________________________________________________________________________________________________________ City                                                                                                   County                                                                                         State                                               Zip Code  Attended from: _____________________________            School Phone: ____________________________             School Fax: __________________________  

Previous School of Attendance (if differs from above):_________________________________________________________________________________ 

 School Address: _________________________________________________________________________________________________________________________                               Street _______________________________________________________________________________________________________________________________________ City                                                                                                   County                                                                                         State                                               Zip Code   Attended from: _____________________________            School Phone: ____________________________             School Fax: __________________________ 

 

Recognizing this legal requirement, I hereby verify that the student named above physically resides within Washington State and all of the above provided information is correct.   Print name of Parent/Guardian/Student : ____________________________Parent/Guardian/Student Signature: ________________________Date:____________  

 **All Students 18 Years and Older Must Sign ALL Enrollment Paperwork** 

 

SCHOOL OFFICIALS ONLY:                                                                                                                                                          Send Records to:  Washington Virtual Academies                                                                                                                                             Official Student Records                                                                                                                                             2601 South 35th Street, Ste 100                                                                                                                                             Tacoma, WA 98409 

  

Vaccine

Dose Date

Month Day Year

+ Hepatitis B (Hep B) 1 2 3

or Hep B - 2 dose alternate schedule for teens

1 2 Rotavirus (RV1, RV5)

1 2 3 + Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT)

1 2 3 4 5 + Tetanus, Diphtheria, Pertussis (Tdap, Td)

1 2 • Haemophilus influenzae type b (Hib)

1 2 3 4 • Pneumococcal (PCV, PPSV)

1 2 3 4

Vaccine Dose Date Month Day Year

+ Polio (IPV, OPV)

1

2

3

4

Influenza (flu, most recent)

+ Measles, Mumps, Rubella (MMR)

1

2

+ Varicella (chickenpox) or verify disease 1-4

1

2

Hepatitis A (Hep A) 1

2

Meningococcal (MCV, MPSV) 1

Human Papillomavirus (HPV) 1

2

3

Office Use Only: Immunization information updated and verified with parent/guardian permission:

Printed Staff Name Date

Printed Staff Name Date

If the child can show immunity by blood test (titer) and hasn’t had the vaccine, ask your HCP to fill in this box.

Documentation of Disease Immunity I certify that the child named on this CIS has laboratory evidence of immunity (titer) to the diseases marked. Signed lab report(s) MUST also be attached. 0 Diphtheria 0 Hepatitis A 0 Hepatitis B 0 Hib 0 Measles

0 Mumps 0 Polio 0 Rubella 0 Tetanus 0 Varicella

0 Other:

Licensed health care provider (HCP) Signature Date (MD, DO, ND, PA, ARNP)

HCP Printed Name:

Certificate of Immunization Status (CIS)

DOH 348-013 January 2010

Please print. See back for instructions on how to fill out this form or get it printed from the Immunization Registry.

Office Use Only: Reviewed by: Date:

Signed Cert. of Exemption on file? 0 Yes 0 No

Child’s Last Name: First Name: Middle Initial: Birthdate (mm/dd/yyyy): Sex: I certify that the information provided on this form is correct and verifiable.

Parent/Guardian Signature Required Date

Symbols below: + Required for School and Child Care/Preschool • Required for Child Care/Preschool Only

Parent/Guardian Name (please print):

If the child named on this CIS had chickenpox disease (and not the vaccine), disease history must be verified. Mark option 1, 2, 3, OR 4 below – see, back #5.

1) 0 Chickenpox disease verified by printout from CHILD Profile Immunization Registry

Must be marked by printout (not by hand) to be valid.

2) 0 Chickenpox disease verified by Health Care Provider (HCP)

If you choose this box, mark 2A OR 2B below. 2A) 0 Signed note from HCP attached OR 2B) 0 HCP signed here and print name below:

Licensed health care provider (HCP) Signature Date

(MD, DO, ND, PA, ARNP)

HCP Printed Name:

3) 0 Chickenpox disease verified by school staff from CHILD Profile Immunization Registry

If you choose this box, staff must initial that parent or guardian approves: (initial) (date)

4) 0 Chickenpox disease verified by parent* If you choose this box, fill in the date or child’s age when he or she had the disease:

Age/Date of disease:

*Can ONLY verify for some grades, see back #5 (4).

Vaccine Dose DateMonth Day Year

+ Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT)

DTaP 1 01 12 2011 DTaP 2 03 20 2011

DTaP 3 06 01 2011

Vaccine Trade Names in alphabetical order (For updated lists, visit http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/us-vaccines-508.pdf)

Trade Name

Vaccine Trade Name

Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine ActHIB Hib Engerix-B Hep B Ipol IPV Pentavalente DTaP + Hep B + Hib TriHIBit DTaP + HibAdacel Tdap Fluarix Flu (TIV) Infanrix DTaP Pneumovax PPSV or PPV23 Tripedia DTaPAfluria Flu (TIV) FluLaval Flu (TIV) Kinrix (Knrx) DTaP + IPV Prevnar PCV or PCV7 or PCV13 Twinrix (Twnrx) Hep A + Hep B Boostrix Tdap FluMist Flu (LAIV) Menactra MCV or MCV4 ProQuad (PrQd) MMR + Varicella Vaqta Hep ACervarix HPV2 Fluvirin Flu (TIV) Menomune MPSV or MPSV4 Quadracel (Qdrcl) DTaP + IPV Varivax VaricellaComvax (Cmvx) Hep B + Hib Fluzone Flu (TIV) Pediarix (Pdrx) DTaP + Hep B + IPV Recombivax HB Hep BDaptacel DTaP Gardasil HPV4 PedvaxHIB Hib Rotarix Rotavirus (RV1)Decavac Td Havrix Hep A Pentacel (Pntcl) DTaP + Hib + IPV RotaTeq Rotavirus (RV5)

Vaccine Abbreviations in alphabetical order (For updated lists, visit http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/us-vaccines-508.pdf)Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name

DT Diphtheria, Tetanus Hep A (HAV) Hep B (HBV)

Hepatitis A Hepatitis B

MPSV or MPSV4 Meningococcal Polysaccharide Vaccine

Rota (RV1 or RV5)

Rotavirus

DTaP Diphtheria, Tetanus, acellular Pertussis Hib Haemophilus influenzae

type bMMR / MMRV Measles, Mumps, Rubella /

with VaricellaTd Tetanus, Diphtheria

DTP Diphtheria, Tetanus, Pertussis HPV Human Papillomavirus OPV Oral Poliovirus Vccine Tdap Tetanus, Diphtheria, acellular

PertussisFlu (TIV or LAIV) Influenza IPV Inactivated Poliovirus

VaccinePCV or PCV7 or PCV13

Pneumococcal Conjugate Vaccine TIG Tetanus immune globulin

HBIG Hepatitis B Immune Globulin MCV or MCV4 Meningococcal

Conjugate VaccinePPSV or PPV23 Pneumococcal Polysaccharide

Vaccine VAR or VZV Varicella

Instructions for completing the Certificate of Immunization Status (CIS): printing it from the Immunization Registry or filling it in by hand.

#1 To print with info filled in: First, ask if your health care provider’s office puts vaccination history into the CHILD Profile Immunization Registry (Washington’s statewide database). If they do, ask them to print the CIS from CHILD Profile and your child’s information will fill in automatically. Be sure to review all the information, sign and date the CIS in the upper right hand box, and return it to school or child care. If your provider’s office does

not use CHILD Profile, ask for a copy of your child’s vaccine record so you can fill it in by hand using steps #2-7 (below):

#2 To fill in by hand: Print your child’s name, birthdate, sex, and your own name in the top box. #3 Write each vaccine your child received under the correct disease. Write the vaccine type under the “Vaccine”

column and the date each dose was received in the “Month,” “Day,” and “Year” columns (as mm/dd/yyyy). For example, if DTaP was received Jan 12, March 20, June 1, ’11, fill in as shown here

#4 If your child receives a combination vaccine (one shot that protects against several diseases), use the Reference Guide below to record each vaccine correctly. For example, record Pediarix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV.

#5 If your child has had chickenpox (varicella) disease and not the vaccine, use only one of these four options to record this on the CIS:

EXAMPLE

1) 0 If your child’s CIS is printed directly from the CHILD Profile Immunization Registry (by your health care provider or school system), and disease verification is found, box 1 is automatically marked. To be valid, this box must be marked by the Immunization Registry printout (not by hand).

2) 0 If your health care provider (HCP) can verify that your child has had chickenpox, mark box 2. Then mark either 2A to attach a signed note from your HCP, or 2B if your HCP signs and dates in the space provided. Be sure your HCP’s full name is also printed.

3) 0 If school staff access the CHILD Profile Immunization Registry and see verification that your child has had chickenpox, they will mark box 3. Then, they must initial and date that they got parent or guardian approval to mark this box (i.e. make this change) to the CIS.

4) 0 If your child started kindergarten in the 2008-2009 school year or later, you CANNOT use this box. If your child started kindergarten before the 08-09 school year, mark this box if you know he or she has had chickenpox. If you mark box 4, you must also write the approximate age or date your child had chickenpox. To find out which grades require chickenpox vaccine (or history), visit: http://www.doh.wa.gov/cfh/immunize/schools/vaccine.htm

#6 Documentation of Disease Immunity: If your child can show immunity by blood test (titer) and has not had the vaccine, have your health care provider (HCP) fill in this box. Ask your HCP to mark the disease(s), sign, date, print his or her name in the space provided, and attach signed lab reports.

#7 Be sure to sign and date the CIS in the upper right hand box, and return to school or child care.

#8 If a school or child care makes a change to your CIS, staff will print their name in the middle bottom box and date to show that you gave approval.

If you have a disability and need this document in another format, please call 1-800-525-0127 (TDD/TTY 1-800-833-6388). DOH 348-013 January 2010

CertificateofExemption

For School, Child Care and Preschool Immunization Requirements1

DIRECTIONS: All exemptions must have a licensed health care provider sign & date Box 1 (‘Provider Statement’).2

Exception: Box 1 is not required for religious exemptions when Box 2 (‘Demonstration of Religious Membership’) is completed. All exemptions must also have a parent/guardian sign & date Box 3 (‘Parent/Guardian Statement’).

Child’s Last Name: First Name: Middle Initial: Birthdate (mm/dd/yyyy): Sex: Parent/Guardian Name (please print):

Parent/Guardian, please choose the exemption(s) that apply to your child below. 0 Temporary Medical Exemption 0 Permanent Medical Exemption

Until Vaccine(s) Date (or Permanent)

Print Name of Licensed Health Care Provider (MD, DO, ND, PA, ARNP)

X X

Signature of Licensed Health Care Provider Date

0 Personal/Philosophical Exemption (see Box 1) 0 Religious Exemption (see Box 1) 0 Religious Membership Exemption (see Box 2) I do not want my child to get the following vaccine(s):

0 Diphtheria 0 Hepatitis B 0 Hib 0 Measles 0 Mumps 0 Pertussis (whooping cough) 0 Pneumococcal 0 Polio 0 Rubella 0 Tetanus 0 Varicella (chickenpox)

0 Other (indicate):

Box 1 Box 2 Provider Statement2: “I, , am a qualified provider (MD, DO, ND, PA, ARNP) licensed under Title 18 RCW. I confirm that the parent or guardian signing in Box 3 (Parent/Guardian Statement) has received information on the benefits and risks of immunization to their child as a condition for exempting their child for medical, religious, personal, or philosophical reasons.” X Signature of Licensed Health Care Provider (MD, DO, ND, PA, ARNP)

X

Date

Parent/Guardian Demonstration of Religious Membership: “I am a member of a church or religious body whose beliefs or teachings do not allow for medical treatment from a health care practitioner. By supplying the information requested below, no further proof or signed provider statement in Box 1 is required for this religious exemption.”

X Name of Church or Religious Body X X Signature of Parent or Guardian Date

Box 3 Parent/Guardian Statement: “I certify that all the information provided on this certificate is correct and verifiable. I understand that if there is an outbreak of a vaccine-preventable disease my child has not been fully immunized against (as indicated above, for medical, personal/philosophical or religious reasons), my child may be at risk for disease and can be excluded from school, child care, or preschool until the outbreak is over.”

X X Signature of Parent or Guardian Date