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Enrollment Form

Vista Horizon Global Academy (LA) Enrollment Form

The questions that are marked by an asterisk (*) are mandatory

Grade Level *:

Student Information

Student's First Name and Last Name *:
Student's Middle Name (Initial):
Gender:
Street Address:
City:
State:
Zip/Postal:
Email:
Primary Phone Number:
Date of Birth *:
Birth Country:
City:
Is the student Hispanic or Latino? *:
Race *:
Student lives with (Check all that apply) *:

Family Information (Based on student's Birth certificate)

Father:

First Name:
Last Name:
Primary Phone/Mobile Phone:
Home Phone:
Work Phone:
Email:

Mother

First Name:
Last Name:
Email Address:
Primary Phone/Mobile Phone *:
Home Phone:
Work Phone/Other phone:

Please complete this section based on who student lives with

Guardian 1

Stepfather:
First Name:
Last Name:
Email:
Primary Phone/Mobile Phone:
Home Phone:
Work Phone:

Home address (if different than student)

Street Address:
City:
State:
Zip/Postal:

Guardian 2

Guardian relationship:
First Name:
Last Name:
Email:
Primary Phone/Mobile Phone:
Home Phone:
Work Phone:

Home address (if different than student)

Street address:
City:
State:
Zip/Postal:
Is parent or guardian a member of the Armed Forces (Army, Navy, Air Force, Marine Corps, or Coast Guard) or on active duty or full-time National Guard duty?:
What is the parent's highest education level attained ? (Mark only one):
Primary Residence *:

Court Orders

ARE THERE ANY COURT ORDERS RESTRICTING THE LEGAL RIGHTS OF EITHER PARENT?
IF YOU ANSWER IS "YES", YOU HAVE TO PROVIDE A COPY OF THE COURT ORDER TO THE SCHOOL OFICE:

Emergency Contact Information

Authorized person to care for/pick up the student if parent/care provider(s) cannot be reached.

In case the school is unable to reach the parent or guardian during any emergency, you authorized the school admits to contact to any of the following. Also you authorized to release your child to any of the following:

Emergency Contact 1

First Name *:
Last Name:
Relationship:
Primary Phone *:
Secondary Phone/Work Phone:
Email:

Emergency Contact 2

First Name:
Last Name:
Relationship:
Primary/Mobile Phone:
Secondary/Home/Work Phone:
Email:

Emergency Contact 3

First Name:
Last Name:
Relationship:
Primary/Mobile Phone:
Secondary/Home/Work Phone:
Email:

Emergency Medical Treatment

Doctor Name and Phone Number:
Hospital Plan:
My child is allergic to the following medications/foods:
Other medications used:

Sibling Information

Sibling 1 *:
First Name:
Last Name:
School Name:
Age:
Sibling 2:
First Name:
Last Name:
School Name:
Age:
Sibling 3:
First Name:
Last Name:
School Name:
Age:
More Siblings:

Home Language Survery

What language did this student learn when first began to talk?:
What language does this student most frequently use at home?:
The language you use most frequently to speak to this student.:
Which language is most often used by adults at home?:
Please specify what is the other language.:
Has this student received any formal English language instruction (listening, speaking, reading, or writing)?:
You prefer to receive your notifications in:

Previous School Information

Date of first U.S. school enrollment:
What Grade?:
What City?:
What State?:
When did your child first attend a public school in California?:
Has student previously attended this school or any Vista Charter Public School?:
If yes, When? What Grade?:

Please list last two schools previously attended

School Name:
School Name:
City, State:
Date Started:
Grade Exited:
Reason for Leaving:
School 2 Name:
City, State:
Date Started:
Grade Exited:
Reason for Leaving:

Special Services

A- Did this student receive special education services at his/her previous school?:
B- Did this student have an Individualized Educational Program (IEP) at his/her previous school?:
C- Did this student have a Section 504 Plan at his/her previous school? :
D- Does this student have difficulties that interfere with his/her ability to go to school or learn? :
E- Did your child receive mental health counseling services at their prior school? :
F- Has this student been identified for gifted and talented educational service (GATE)? :
If the answer of any of the above question is YES, please provide a copy of related documents.

Federal Poverty Guideline

How many persons are in the family household? *:
Household Annual Income is up to *:

Migrant Education Program Family Questionnaire

Have you ever worked in any of the following industries at least 15 continuous days in the last three years? Please select all that apply *:
If you have worked in one or more of above mentioned industries, your child may be eligible to receive additional free educational services which will help your child be more successful in school. Please check if you are interested in any of the following programs and call the school office to make an appointment.:

PARENT/GUARDIAN PUBLICITY AUTHORIZATION AND RELEASE

Vista Charter Public Schools requests your permission to reproduce through printed, audio, visual, or electronic means activities in which your pupil has participated in his/her education program. Your authorization will enable us to use specially prepared materials to (1) train teachers and/or (2) increase public awareness and promote continuation and improvement of education programs through the use of mass media, displays, brochures, websites, etc.a)
I, as a parent or guardian, of the student fully authorize and grant Vista Charter Public Schools and its authorized representatives, the right to print, photograph, record, and edit as desired, the biographical information, name, image, likeness, and/or voice of the above named pupil on audio, video, film, slide, or any other electronic and printed formats, currently developed, (known as “Recordings”), for the purposes stated or related to the above.b) I understand and agree that use of such Recordings will be without any compensation to the pupil or the pupil’s parent or guardian.c) I understand and agree that Vista Charter Public Schools and/or its authorized representatives shall have the exclusive right, title, and interest, including copyright, in the Recordings.d) I understand and agree that the Vista Charter Public Schools and/or its authorized representatives shall have the unlimited right to use the Recordings for any purposes stated or related to the above.e) I hereby release and hold harmless Vista Charter Public Schools and its authorized representatives from any and all actions, claims, damages, costs, or expenses, including attorney’s fees, brought by the pupil and/or parent or guardian which relate to or arise out of any use of these Recordings as specified above.
My initial and signature show that I have read and understood the release and I agree to accept its provisions.

PARENT/GUARDIAN PUBLICITY AUTHORIZATION AND RELEASEDIRECTORY INFORMATION OPT-OUT OPTION

“Directory information,” which is defined as set forth below, may be released to requestors in limited circumstances by Vista Charter Public Schools, without additional notice to you, unless you timely “opt out” of such disclosures, in writing. State and federal law allow directory information to be disclosed to any requestors, except those who intend to use the information for commercial purposes. However, this school's policy is to not release directory information to any requestor, for any purpose, without specific prior parent/guardian consent in each situation, EXCEPT we will release such information to requestors that engage in political advocacy, lobbying, or information dissemination related to California charter schools, specifically in this instance to the California Charter Schools Association Advocates. If you do not want Vista Charter Public Schools to disclose your contact and other directory information from your child's records to such persons or entities without your prior written consent, you must notify us in writing by September 1st, of each school year.
Vista Charter Public Schools has designated the following information as directory information:
- parents’/guardians’ names
- Address
- Email address
- Phone number
- Dates of attendance
- Participation in officially recognized activities and sports
- Weight and height of members of athletic teams
- Degrees, honors, and awards received
- The most recent educational agency or institution attended
Media Release of Information:

STUDENT TECHNOLOGY USE POLICY

Vista Charter Public Schools (VCPS) provides computers and/or computer Internet access available to students. Computers are useful for students to perform research and to allow students to learn how to use computer technology. Use of VCPS computers is for educational and instructional purposes only. It is the policy of VCPS to equip each computer with internet filtering software designed to prevent users from accessing material that is harmful to minors. Students will not be granted laptop access or internet access unless the parent/legal guardian sign this computer-use agreement. Students are advised that they will not have any privacy of their computer use, including email, and that monitoring of student computer use will be performed by VCPS authorized personnel. Students who misuse school-owned computers or internet access in any way will face disciplinary action as specified in the student
1. Treat the computer/technology as if it were your own!
2. Inspect computer/technology before use
3. Must use your assigned computer/technology at all times.
4. Clean hands please.
5. Listen for directions.
6. Only use the program/webpage that the teacher says to use.
7. Keep the computer/technology on the assigned desk.
8. Close the computer/technology before walking around.
9. Never download without the teacher's permission.
10. Never put memory sticks, cards or disks from home in school computer/technology.
11. No water bottles or other drinks around the computer/technology.
12. Do not use someone else's computer/technology without permission.
13. Do not access or change any of the computer/technology settings for any reason.
14. If there is any damage the computer/technology due to carelessness or misuse there will be a financial responsible.
15. Sign out when computer is not in use.
16.Please clean hands prior to using your assigned device

ACKNOWLEDGEMENT

Dear Parents and students,It is your responsibility to read and become familiar with the information contained in the Parent/Student Handbook of Vista Charter Public Schools. Please visit www.vistacharterpublicschools.org and click on “Parent/Student Handbook” to review this document. If you are unable to access this document online, you may obtain a hard copy form the school’s main office.Your signature below, acknowledges that you have read, understood, and agree with the information contained in the Vista Charter Public Schools Parent/Student Handbook

SIGNATURE

I verify that this information is true and correct
Date:
Signature of:
Confirmation Email *: