Enrollment Forms Packet (EFP)

Required For? Item Description Provided by?

Required for all Students

Proof of Age Official Birth Certificate (not the hospital issued certificate) Provided by you

Proof of Residency Current Utility bill showing service address OR Mortgage statement/Rental Contract including signature page Provided by you

Immunization Record

Current Immunization Record OR a notarized exemption letter from the Legal Guardian and is due within 60 days of your student’s approval date. Provided by you

Eye, Ear and Dental Screening

This must be on Georgia Form 3300 and is due within 60 days of your student’s approval date. Provided by you

Family Income Form Please complete form and submit Provided in this

packet

Release of Records

By filling out this form, you are giving our school permission to request your student’s official records from their previous school after the approval process. If your child is enrolling in Kindergarten or was Homeschooled please indicate it on the form, fill out the top portion and sign it.

Provided in this packet

Required for all High School Stu-dents

Unofficial Tran-script/Report Card

You will need to request an unofficial transcript/report card from your stu-dent’s current school, which will show your student’s academic standing. This is required in order to place all High School students. Once your student is ap-proved, we will request the official transcript.

Provided by you

Required for student with an IEP or other Special Education needs

IEP A copy of your student’s current IEP (Individualized Education Plan). Because the IEP expires yearly, please submit the current IEP. Provided by you

Evaluation Report The Evaluation Report is valid for 3 years. If you do not have a copy of your student’s ER, you can request a copy from your student’s current school. Provided by you

Required for stu-dents that have a 504 plan

504 Accommoda-tion Plan

A copy of your student’s current 504 Accommodation Plan. Because the 504 expires yearly, please submit the current 504. Provided by you

Based on your student(s) grade and applicable circumstances, complete one enrollment package and review the information below to determine what you should submit for each student seeking admission to the Georgia Cyber Academy School (GCA). You can fax, scan and email, or mail the required paperwork.

Important Note: Please send copies, do not mail the original documents

Fax (preferred): Scan and Email: Mail: 1-866-991-3020 gcafax@k12.com Georgia Cyber Academy Enrollment Processing Center 2300 Corporate Park Drive Suite 200 Herndon, VA 20171

Georgia Cyber Academy Enrollment Processing Center 2300 Corporate Park DriveSuite 200Herndon, VA 20171 Ph. 877.882.1267Fx. 866.991.3020www.k12.com/gca

Student InformationStudent’s Full Name:

first middle last

Student’s Date of Birth: Social Security Number:

Student’s Legal Address: street apt #

city county state zip

Home Phone:

Check below if applicable: o Student was always previously homeschooled

o Student is enrolling in Kindergarten

Name of Prior School:

School’s Address: street

city county state zip

School’s Phone: School’s Fax:

I authorize The Georgia Cyber Academy to request and receive my student’s records from any school that has posession of the records

Print Parent or Legal Guardian’s Name: Date:

Parent/Legal Guardian’s Signature:

Release of Student RecordsPlease 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).

Homeschooled or Never Previously Enrolled in School (Fill out only if applicable)

Prior School Information

Sign and Date below

SCHOOL OFFICIALS ONLY:

Send student records to: Georgia Cyber Academy 503 Oak Place Suite #540 Atlanta, GA 30349

Student’s Name: Student’s Home Phone:

1

Georgia Cyber Academy Enrollment Processing Center 2300 Corporate Park DriveSuite 200Herndon, VA 20171 Ph. 877.882.1267Fx. 866.991.3020www.k12.com/gca

2012-2013 Family Income Form

Student Information

In order to determine if GCA will receive federal Title I funds for reading and/or mathematics or other services, certain information is needed. Please complete this form and submit it with your enrollment documents. List only those students enrolled in GCA.

Please print the name of all children enrolled in GCA.

Calculating Household IncomeIn order to determine if GCA will receive Title I funds, you will have to calculate the total amount of income in your household. Include all income for all household members (include yourself, all children in the home, your spouse, grandparents, and all others related and unrelated in your household). See lists below of the type of income to report.

Earnings from work:o Wages/salaries/tipso Strike benefitso Unemployment Compensation o Worker’s Compensation o Net income from self-owned business or farm

Pensions/Retirements/Social Security:o Pensionso Supplemental Security Income o Retirement income o Social Security

Public Assistance/Child Support/Alimony:o Public assistance/welfare paymentso Alimony/child support payments

Other Income:o Disability benefitso Interest dividendso Cash withdrawn from savingso Estate/trusts/investmentso Regular contributions from person(s) not living in householdo Net royalties/annuities/net rental income

Certification and SignatureI certify that all of the above information is true and correct, and that all income is reported. I understand this information is being given for the receipt of federal funds, and that school officials may verify the information on the form.

Parent/Guardian’s Signature: Date:

Household Income

Total number of all household members, whether they receive income or not:

Total of all household members’ income before taxes or anything else is taken out. Fill in the one that is easiest for you to calculate:

$ OR $ OR $ annually monthly weekly

NAME BIRTH DATE SEX GRADE

DISTRICT OF RESIDENCE (WHERE YOU LIVE)

INDICATE IF CHILD IS A FOSTER CHILD, WARD OF COURT, OR FOOD STAMP RECIPIENT

Student’s Name: Student’s Home Phone:

4

Georgia Cyber Academy Enrollment Processing Center 2300 Corporate Park DriveSuite 200Herndon, VA 20171 Ph. 877.882.1267Fx. 866.991.3020www.k12.com/gca