Enrollment Forms Packet (EFP)Please review the information below. Based on your student(s) grade and applicable circumstances, you are required to sub-mit 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): Scan and Email: Mail: 1-877-890-5481 mavafax@k12.com MassachusettsVirtualAcademyatGreenfield Enrollment Processing Center 2300 Corporate Park Drive Suite 200 Herndon, VA 20171

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 Provided by you

Reason for Enroll-ing Please complete form and submit. Provided in this

packet

Residency Affidavit Please complete form and submit. Provided in this packet

Preliminary 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

Family Income Form

Please complete form and submit. *If you would like to Opt out of this form, please write Opt Out on the student on the student information section of this form, sign and submit.

Provided in this packet

Report Card A copy of the students most recent report card Provided by you

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 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

Massachusetts Virtual Academy @ Greenfield(Enrollment Processing Center) 2300 Corporate Park DriveSuite 200Herndon, VA 20171 Ph. 866.467.0843Fx. 877.890.5481 www.k12.com/mava

Greenfield Public Schools Greenfield, Massacusetts

Page 1 of 1 Reason for Enrolling 2012-2013

Massachusetts Virtual Academy @ Greenfield 2300 Corporate Park Drive, Ste. 200

Herndon, VA 20171

REASON FOR ENROLLING

Please provide information as to the primary reason you are considering Massachusetts Virtual Academy @ Greenfield for your student. Check the appropriate box.

 ___ 1.) Student has a medical condition(s) that interferes with attendance

 ___ 2.) Student has developmental, social-emotional, instructional, or unique individual learning needs well served by the virtual school design and structure

 ___ 3.) Safety issues in attending school are interfering with attendance,

 ___ 4.) Student needs an advanced course program not available in their assigned school ___ 5.) Student is involved in competitive arts or sports whose days are used for training and practice

 ___6.) Student is out of school due to pregnancy or parenting

 ___ 7.) Student works during the day to help with personal or family support

 ___ 8.) Student has dropped out of school and/or whose original high school class has since graduated

 ___ 9.) Student has other reasons of a compelling nature, not defined above.

DESCRIBE:  Student Name Parent Name Date Parent Signature

Page 1 of 1 Residency Affidavit 2012-2013

Massachusetts Virtual Academy @ Greenfield 2300 Corporate Park Drive Ste. 200

Herndon, VA 20171

RESIDENCY AFFIDAVIT I attest that I am the legal guardian of the child/children listed below: Name DOB

Name DOB

Name DOB

and that I and the above-named child/children are legal residents of and

reside in the City/Town of Our physical

address is:

I have been residing at this address since . I intend to continue as a resident of for the 2012-2013 school year. I agree that, immediately upon any change in my residency or the residency of my children, I shall inform the principal of my children’s school. The facts set forth in this residency affidavit are true and complete. I understand that providing misleading or false information about residency is a criminal offense. Date Printed Name Signature

Greenfield Public Schools Greenfield, Massachusetts 

Preliminary request for Student Records 2012‐2013 School Year 

                                                                                       has applied to Massachusetts                                                                     (Name) 

 Virtual Academy, a state‐wide Innovation School of the Greenfield Public Schools, for the 2011‐2012 school year.  In order to ascertain eligibility, please forward the following information to:                              HPA                             Massachusetts Virtual Academy                             141 Davis Street                             Greenfield, MA 01301                             Fax  (413) 475‐3909   

          Copy of Current Report Card                                        MCAS scores           Academic & Attendance Records                                Discipline Records           I E P (if applicable)                                                          Home School Plan           504 Plan (if applicable)                                                  E L L  Records           Health Records                                                                Other  In order for an application to be considered complete, all applicable documents must be received by the Massachusetts Virtual Academy.  

 I hereby authorize release of all records requested 

X(Signature of Parent and/or Guardian)

                                                                                        

FREE AND REDUCED PRICE SCHOOL MEALS FAMILY APPLICATION

PART 1. ALL HOUSEHOLD MEMBERS (USE A SEPARATE APPLICATION FOR EACH FOSTER CHILD)

Names of household members

(First, Middle Initial, Last) School Name for Each Child

[State SNAP], [FDPIR] or [State TANF] case

number for any member of the household. If you

list a case number, skip to Part 5

CHECK

IF NO INCOME

�

�

�

�

�

�

PART 2. IF ANY CHILD YOU ARE APPLYING FOR IS HOMELESS, MIGRANT, OR A RUNAWAY CHECK THE APPROPRIATE BOX AND CALL [YOUR SCHOOL, HOMELESS LIAISON, MIGRANT COORDINATOR AT PHONE #] HOMELESS � MIGRANT � RUNAWAY �

PART 3. FOSTER CHILD If this application is for a child who is the legal responsibility of a welfare agency or court, check this box � and then list the

amount of the child’s personal use monthly income: $__________. � Check if no income. Skip to Part 5.

PART 4. TOTAL HOUSEHOLD GROSS INCOME. You must tell us how much and how often

1. NAME

(List all household members with income)

2. GROSS INCOME AND HOW OFTEN IT WAS RECEIVED

Earnings From Work

before deductions

Welfare, child support,

alimony

Pensions, retirement, Social

Security, SSI, VA benefits All Other Income

(Example) Jane Smith $199.99/weekly_

_

$149.99/every other week $99.99/monthly____ $______/________

$______/________ $______/________ $______/________ $______/_______

$______/________ $______/________ $______/________ $______/_______

$______/________ $______/________ $______/________ $______/_______

$______/________ $______/________ $______/________ $______/_______

$______/________ $______/________ $______/________ $______/_______

$______/________ $______/________ $______/________ $______/_______

PART 5. SIGNATURE AND SOCIAL SECURITY NUMBER (ADULT MUST SIGN)

An adult household member must sign the application. If Part 4 is completed, the adult signing the form also must list his or her Social Security

Number or mark the “I do not have a Social Security Number” box. (See Privacy Act Statement on the back of this page.)

I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get Federal funds

based on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false

information, my children may lose meal benefits, and I may be prosecuted.

Sign here: ______________________________________________________________________Print name:____________________________________________________________________

Date: ____________________________

Address:_____________________________________________________________________________________Phone Number:_______________________

City:___________________________________________________________________________State:__________________Zip Code:_____________________

Social Security Number: __ __ __ - __ __ - __ __ __ __ � I do not have a Social Security Number

PART 6. CHILDREN’S ETHNIC AND RACIAL IDENTITIES (OPTIONAL)

Choose one ethnicity: Choose one or more (regardless of ethnicity):

� Hispanic/Latino

� Not Hispanic/Latino

� Asian � American Indian or Alaska Native � Black or African American

� White � Native Hawaiian or other Pacific Islander

DON’T FILL OUT THIS PART. THIS IS FOR SCHOOL USE ONLY.

Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24 Monthly x 12

Total Income: ____________ Per: � Week, � Every 2 Weeks, � Twice A Month, � Month, � Year Household size: ________

Categorical Eligibility: ___ Date Withdrawn: ________Eligibility: Free___ Reduced___ Denied___ Reason: _______________________________________

Temporary: Free_____ Reduced_____ Time Period: ___________ (expires after _____ days)

Determining Official’s Signature: ________________________________________________ Date: ______________

Confirming Official’s Signature: _____________________________ Date: ___________ Verifying Official’s Signature: ______________________________ Date: ________

Your children may qualify for free

or reduced price meals if your

household income falls at or below

the limits on this chart.

Privacy Act Statement: This explains how we will use the information you give us.

The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but

if you do not, we cannot approve your child for free or reduced price meals. You must include the social security number of the adult

household member who signs the application. The social security number is not required when you apply on behalf of a foster child or you

list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution

Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult

household member signing the application does not have a social security number. We will use your information to determine if your child

is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share

your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their

programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules.

Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly. “In accordance with Federal

law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin,

sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW,

Washington, D.C. 20250-9410 or call (800) 795-3272 or (202) 720-6382 (TTY). USDA is an equal opportunity provider and employer.”

FEDERAL ELIGIBILITY INCOME CHART For School Year________

Household size Yearly Monthly Weekly

1

2

3

4

5

6

7

8

Each additional person:

Student’s Name: Student’s Home Phone:

7

Massachusetts Virtual Academy @ Greenfield(Enrollment Processing Center) 2300 Corporate Park DriveSuite 200Herndon, VA 20171Ph. 866.467.0843Fx. 877.890.5481www.k12.com/mava

SCHOOL OFFICIALS ONLY:

Send student records to: Massachusetts Virtual Academy @ Greenfield Greenfield School Administration Building 141 Davis Street Greenfield, MA 01301

Please accept this document as formal approval for the release of all official school records (including the record of transcripts, testing information, prior special education evaluations, IEP/special education progress report, any additional special education records, health and immunization records).

Release of Student General Education and/or Special Education Records

Student InformationStudent’s Full Name:

first middle last

Student’s Date of Birth:

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:

Name of Parent or Legal Guardian: first last

Parent/Guardian’s Signature: Date:

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

Prior School Information

Sign and Date below