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PA Leadership Charter School 1332 Enterprise Drive West Chester, PA 19380

Dear Parents and Students:

Welcome to the Leadership Charter School (PALCS), a leader in cyber education since 2004. We currently serve over 3,000 students in grades K through 12 and have proudly graduated over 3,500 students. PALCS faculty and staff are committed to partnering with you to provide your student with comprehensive, high-quality instruction using cutting-edge, online technology. Working together as a team, it is our goal to offer your student the tools necessary to be successful in any educational endeavor.

Included in this packet are the documents that you will need to complete and submit to the PALCS Admissions Department. Make sure to complete all pages for each document and sign where requested. Read all policies or rules related to those documents.

Students enrolling in public school must show documentation of immunization, proof of residency, and proof of age. Please review the “Checklist” provided in your packet for a list of additional documents needed to complete the registration process.

Again, welcome to the PALCS team and thank you for making Pennsylvania Leadership your public school choice.

Sincerely,

Dr. James Hanak CEO, PA Leadership Charter School

1332 Enterprise Drive • West Chester, PA 19380 • www.palcs.org Phone (610) 701-3333 • Fax (610) 701-3339

What Happens Next?

Step 1 - Application

 Complete the enclosed registration forms.

Please refer to the Registration Packet Checklist for additional necessary documentation.

 Mail your completed packet(s) to the appropriate office:

If you live closer to : If you live closer to : PALCS PALCS 1332 Enterprise Drive The Landings West Chester, PA 19380-5970 55 Alpha Drive West Pittsburgh, PA 15238-1401

PALCS will notify you within 1-2 business days of receipt of your paperwork.

 An Orientation is scheduled upon receipt of the completed Registration Packet and all required documents.

Do not withdraw your child from his/her school until after the orientation appointment.

Step 2 – Orientation

All students and Parents/Guardians are required to attend an orientation at one of the above PALCS offices prior to enrollment. During the orientation, student and Parent/Guardian receive a brief overview presentation and hands-on training on the school’s website.

Regional orientations are scheduled on the basis of demand. We will do our best to accommodate all applicants but cannot guarantee orientations will be scheduled in your vicinity.

 What do I need to bring to Orientation?

o The original or reissued Birth Certificate (not a copy) or the original notarized Birth Certificate Affidavit for each student.

o Any other documents you are advised to bring that are required to enroll your student.

o Glasses or contacts if your student wears them.

Step 3 – Enrollment

Upon completion of all of the requirements listed above, your student will be enrolled.

Welcome to PALCS!

Page 1 of 1

Registration Checklist

Listed below is a checklist of items that MUST be returned to Pennsylvania Leadership Charter School. Please use this document to your submissions to us and ensure that you complete all requirements for registration.

State of Pennsylvania Charter School Enrollment Notification Form PALCS Enrollment Form Release of Student Information Form (Do not send to student’s former school.) Parental Registration Statement – Act 26 PALCS Enrollment Agreement Family Income Form Request for Reimbursement Form Home Language Survey Form Why I Chose PALCS Form Release of Photo and Directory Information and Permission for Text Messaging Signature Form State-Mandated Testing Agreement Form School-Parent Compact Form School Health Information Form Private Dental Report Private Physician’s Report Emergency Care Information Form

Additional Required Information: □ Proof of Child’s Age—Please provide a copy of one of the following: birth certificate, baptismal certificate, copy of the record of baptism showing the date of birth, notarized statement from the parents or another relative indicating the date of birth, or a valid passport. NOTE: You are required to bring the original with you to orientation. □ Current Forms of Residency Confirmation—Please include a copy of any two (2) of the following items: driver’s license or DOT identification card, current utility bill, deed, lease, property tax bill, or vehicle registration. Driver's License must be current. Document must be in the name of the homeowner or payee, must reflect the current address, and must be current (within the past 30 days). Items NOT acceptable: credit card statement, bank statement, envelope, checks, etc. □ Immunization Records—Please provide a written record from a medical office or former school district that the required immunizations have been administered. □ Medical/Dental Forms—Please refer to the Health and Immunization Requirements (which is included in this packet) to see which medical forms you need to complete. NOTE: You do NOT need to complete the appropriate physical or dental exams before enrolling. □ Report Card/Transcript

 Elementary (K-5)—Please provide a copy of the most recent report card.  Middle School and 9th (6-9)—Please provide a copy of the most recent report card.  High School (10-12)—Please provide a copy of the unofficial high school transcript and the most recent report card.  Homeschool Report Card/Transcript (if homeschooled)—also include signed evaluations from the previous year and for each year of high school.

NOTE: If enrolling in the middle of the year, include grades/progress reports for every completed quarter of the current school year. □ Special Education Documents (if applicable)—Parent MUST include a copy of the student’s most recent IEP (Individualized Educational Program) & NOREP (Notice of Recommended Educational Placement), the Initial ER (Evaluation Report), all RR’s (Reevaluation Reports), most recent Invitation to Participate, all Permission to Evaluate and/or Waiver forms, and any other psychological or related service evaluations pertaining to Special Education.

□ ESL (English as a Second Language) records (if applicable). □ Proof of home service – copy of current bill or statement of service is acceptable. Page 1 of 1

Pennsylvania Leadership Charter School

Annual Public Notice (504)

In compliance with state and federal law, the Pennsylvania Leadership Charter School will provide each protected handicapped student, without discrimination or cost to the student or family, those related aids, services, or accommodations which are needed to provide equal opportunity to participate in and obtain the benefits of the school program and extracurricular activities to the maximum extent appropriate to the student’s abilities.

In order to qualify as a protected handicapped student, the child must be of school age with a physical or mental disability that substantially limits or prohibits participation in or access to an aspect of the school program. These services and protections for protected handicapped students are distinct from those applicable to all eligible or exceptional students enrolled, or seeking enrollment, in special education programs.

For further information on the evaluation procedures and provisions of services to protected handicapped students, contact PALCS at 610-701-3333, or via email at [email protected].

page 1 of 1 APN 19-20 (22 Pa Code Chapter 15.4)

1332 Enterprise Drive • West Chester, PA 19380 • www.palcs.org Phone (610) 701-3333 • Fax (610) 701-3339 Charter School Student Enrollment Notification Form For School Year 2019-2020 Warning: A child enrolled in another public school or a nonpublic or private school cannot, at the same time, enroll in a charter school. Name of Charter School: Pennsylvania Leadership Charter School Address: 1332 Enterprise Drive West Chester, PA 19380 Charter School Contact Person: Debby Weisbach Email Telephone: 610.701.3333, ext.1109 Address: [email protected]

I. Student Information: Last First Name: Name: MI: Home Address: : State: Zip Code: County: Telephone: Mailing Address (If Different From Home Address) City: State: Zip Code:

Date Of Birth: Age:

II. School District of Residence and Former School Information: School District of Residence:

Former School Information (Other Than Pre-School): Public Charter Home School School School Nonpublic School Student Not Enrolled in School Preceding Enrollment in Charter School Because: Entering Kindergarten Re-Enrolling Dropout Other Name of Former School: Address of Former School:

Previous Grade: Withdrawal Date From Former School:

Was Your Child Receiving Special Education Services Based On An IEP? Yes No

If Yes, Do You Have The Child’s Special Education Records (IEP)? Yes No Page 1 of 2

III. Parent/Guardian Information: Both Both Parents Mother Father Child Lives With: Parents Alternately Only Only Legal Foster Guardian Parents Other Adult Special Custodial Court Instructions: (If Yes, Please Provide a Copy of Court Order.) Yes No

Complete Parent/Guardian Name and Address Information As Applicable

Father’s Name: Address: City: State: Zip Code: Primary Telephone: Alternate Telephone:

Mother’s Name: Address: City: State: Zip Code: Primary Telephone: Alternate Telephone:

If The Student Is Not Living With Parents, Please Complete This Section. Guardian’s Name Or Foster Parent’s Name Or Other Adult Name Name: Address: City: State: Zip Code:

My signature on this form indicates my decision to have my child attend the charter school named on page 1 of this form and signifies my request that appropriate school records be forwarded from the school district to the charter school. My signature also certifies that my child is not, and will not be, enrolled in another public school, a nonpublic school or a private school at the same time he or she is enrolled in this charter school. Signature of Parent/Guardian: Date:

IV. To Be Completed By Charter School:

Verification of Date of Birth: Birth Certificate Other Proof of Mortgage Utility Residency Statement Lease Bill Other Official Enrollment Date: Anticipated Date of Attendance: Grade Student Is Entering: Signature of Charter School Representative:

Page 2 of 2

PA Leadership Charter School 1332 Enterprise Drive West Chester, PA 19380 Enrollment Form Phone: 610.701.3333 2019-2020 School Year Fax: 610.701.3339 www.palcs.org

Student’s Legal Name: ______last first middle

Preferred Name: ______Gender: Male Female Age: ______

Student's DATE of BIRTH: ______Student's CITY of BIRTH: ______

Student's STATE of BIRTH: ______Student's COUNTRY of BIRTH: ______

Grade enrolling in THIS YEAR (2019-2020): K 1 2 3 4 5 6 7 8 9 10 11 12

Grade Level LAST YEAR (2018-2019): K 1 2 3 4 5 6 7 8 9 10 11 12

What is the student’s ethnicity?

Hispanic or Latino (any race) Not Hispanic or Latino

What is the student’s race? Select one or more races to indicate the student’s racial identity.

White Black/African American Asian American Indian/Alaskan Native Native Hawaiian/Other Pacific Islander

For students entering grades 9-12 for the 2019-2020 school year: What year did student first enter 9th grade?

2019-2020 2018-2019 2017-2018 2016-2017 2015-2016 2014-2015 2013-2014

Has the student ever lived outside the state of Pennsylvania? YES NO

If “YES,” please provide the DATE that the student most recently entered PA (mm-dd-yyyy): ____-____-______

OR, if that is not possible, please provide the most recent date the student enrolled in a school in PA:

(mm-dd-yyyy): ____-____-______

Has the student ever lived outside of the United States? YES NO

(Please note: A territory of the U.S. does not count as enrollment in a U.S. school. Territories include: Guam, Northern Mariana Islands, Puerto Rico, American Samoa, Palau, and the United States Virgin Islands.)

IF YES, what DATE did the student most recently enter the United States? (mm-dd-yyyy): ____-____-______

IF YES, what DATE did the student first enroll in a US School? (mm-dd-yyyy): ____-____-______

Mailing Address

Street: ______Apartment: ______

City: ______State: ______Zip Code: ______-______

Primary Phone: ______

Shipping Address (Must be the physical address of parent or guardian for materials delivery. No post office (P.O.) boxes. We cannot ship instructional materials without a physical address.)

Check if SAME as Mailing Address

Street: ______Apartment: ______

City: ______State: ______Zip Code: ______-______

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PLEASE NOTE: If you are planning to move, please be sure to notify PALCS in writing, or call the school at 610.701.3333, immediately. Shipping occurs periodically throughout the school year for some courses. Failure to notify PALCS of an address change may result in delayed materials receipt.

Special Programs Information

To help us better serve your student’s needs and transition, we would like to know about any special services your student has received or is required to receive under state or federal law. This information will not be used to determine enrollment eligibility, but will be used to ensure that your child is provided with proper services.

Has your student participated in any of the following special services? Special Education Gifted & Talented ESL (English as a Second Language) Title 1/Chapter 1 504 Plan Does your student have an Individual Education Plan (IEP)? Yes No If yes, do you have a copy of the IEP? Yes No If yes, please enclose a copy. A copy must be received to assist in meeting your student’s needs.

Emancipated Minor Information Is the student an emancipated minor? Yes No

A student is considered emancipated if he/she is under 21 years of age and one or more of the following:

 Established a home apart from the control and support of their parents/guardians  Married and living with his/her spouse  Deemed legally emancipated

Internet Information

Do you currently have access to the internet? Yes No

If yes, who is your internet provider? ______

Parent/Guardian Information

Mother/Guardian’s Name: ______

Mother/Guardian’s Mailing Address: Same as student’s

Street: ______Apartment: ______

City: ______State: ______Zip Code: ______-______

Primary Phone: ______Alternate Phone: ______

E-Mail Address: ______

Is there a step-parent in the home? Yes No

If yes, what is the step-parent’s name? ______

What is the mother/guardian’s primary spoken language: ______

What other languages does the mother/guardian speak? ______

Does the mother/guardian need an interpreter? Yes No

Is the student’s mother/guardian currently serving in the active duty military? Yes No

Is the student’s mother/guardian a federal employee? Yes No

Is the student’s mother/guardian a migrant worker? Yes No

Page 2 of 3

Father/Guardian’s Name: ______

Father/Guardian’s Mailing Address: Same as student’s

Street: ______Apartment: ______

City: ______State: ______Zip Code: ______-______

Primary Phone: ______Alternate Phone: ______

E-Mail Address: ______

Is there a step-parent in the home? Yes No

If yes, what is the step-parent’s name? ______

What is the father/guardian’s primary spoken language: ______

What other languages does the father/guardian speak? ______

Does the father/guardian need an interpreter? Yes No

Is the student’s father/guardian currently serving in the active duty military? Yes No

Is the student’s father/guardian a federal employee? Yes No

Is the student’s father/guardian a migrant worker? Yes No

Page 3 of 3

PA Leadership Charter School 1332 Enterprise Drive West Chester, PA 19380

Release of Student Information

Former School or School District: ______

School Address: ______

City, State, Zip: ______

School Phone Number: ______

The following student indicated that he/she previously attended your school:

Student Name: ______Date of Birth: ______

Student Address: ______

City: ______State: ______Zip: ______

Please send all cumulative records you may have pertaining to this student, including:

 Academic Records  PSSA Scores  Standardized Test Scores (Please provide IOWAs, CATs, DIBELS, SAT, PSAT, ACT, Keystones, or any other school-wide standardized test scores.)  Attendance record, including SAIP (Student Attendance Improvement Plan) if applicable  ACT 26 Certified Discipline Records  Dental, Health, & Immunization Records  Special Education Documents (if applicable): Please include a copy of the student’s most recent IEP (Individualized Educational Program) & NOREP (Notice of Recommended Educational Placement), the Initial ER (Evaluation Report), all RR’s (Reevaluation Reports), most recent Invitation to Participate, all Permission to Evaluate and/or Waiver forms, and any other psychological or related service evaluations pertaining to Special Education  ESL (English as a Second Language) documents (if applicable)

Forward records to: Pennsylvania Leadership Charter School Attn: Student Records 1332 Enterprise Drive West Chester, PA 19380 E-Mail: [email protected]

Thank you for your prompt attention to this matter.

Signature of Parent or Guardian: ______Date:______

Signature of PALCS Representative: ______Date:______

Page 1 of 1 PA Leadership Charter School 1332 Enterprise Drive West Chester, PA 19380

Parental Registration Statement – Act 26

Student’s Name: ______

PA Leadership Charter School is committed to comply with the Safe Schools Act to ensure the safety and well-being of our students. According to Pennsylvania Act 26 of 1995, “Prior to admission to any school entity, the parent, guardian, or other persons having control or charge of a student shall, upon registration, provide a sworn statement or affirmation stating whether the pupil was previously suspended or expelled from any public or private school of this Commonwealth or any other State for an act or offense involving weapons, alcohol or drugs, or for the willful infliction of injury to another person or any act of violence committed on school property. The registration shall include the name of the school from which the student was expelled or suspended for the above-listed reasons with the dates of expulsion or suspension and shall be maintained as part of the student’s disciplinary record.” In addition, under Act 26 of 1995, “any willful false statement made under this section shall be a misdemeanor of the third degree.”

I hereby swear or affirm that my child (was □) (was not □) previously suspended or (is □) (is not □) presently suspended from any public or private school of this Commonwealth or any other state for an act or offense involving weapons, alcohol or drugs, or for the willful infliction of injury to another person or for any act of violence committed on school property.

I hereby swear or affirm that my child (was □) (was not □) previously expelled or (is □) (is not □) presently expelled from any public or private school of this Commonwealth or any other state for an act or offense involving weapons, alcohol or drugs, or for the willful infliction of injury to another person or for any act of violence committed on school property.

I make this statement subject to the penalties of 25 P.S. §13-1304-A(b) and 18 PA.C.S.A. §4904 relating to unsworn falsification to authorities, and the facts contained are true and correct to the best of my knowledge, information, and belief.

Please complete this section if the student has been or is presently suspended or expelled from another school.

Name of school from which the student was suspended or expelled:

Dates of suspension or expulsion: (Please provide additional schools and dates of suspension/expulsion if applicable.)

Reason for suspension or expulsion:

______Parent/Guardian Signature Date .

Page 1 of 1

Pennsylvania Leadership Charter School Attendance Policy

Per the Pennsylvania Department of Education (PDE), “The school can be effective in educating a child only if the child is in school.”

State law requires Pennsylvania Leadership Charter School (PALCS) to be open 180 days a year and in operation for 990 hours. In compliance with this law, PALCS has established and published a 180-day academic calendar.

The attendance requirement is met by logging in to PALCSchool each school day listed in the academic calendar. As a virtual school, student attendance is verified by electronically logging on to PALCSchool. If a student fails to log in to PALCSchool, he or she is absent.

Please note that, as part of your student’s curriculum, she/he may be required to attend virtual lessons/sessions one or more times per week. Absences from mandatory virtual lessons may adversely affect the student’s grade.

Attendance and participation in onsite state assessments are also mandatory. Each missed day of scheduled state assessments will be documented as one unlawful absence.

Occasionally, students are unable to log on and complete their schoolwork on a given day; this is considered an absence. Acceptable reasons for a student absence include illness or injury, medical appointments, family emergencies, observance of religious holidays, educational opportunities or family trips (see Student Educational Leave of Absence below).

In the case of a system-wide failure of PALCS that prohibits students from logging in to PALCSchool and completing their work, no absence will be charged to the student. In the event of such a school-wide outage that prohibits children from attending and completing their work, an additional school day will be added to the school calendar and families will be notified of the change.

In the case of a computer or technical issue with the student, parents are asked to immediately contact the HelpDesk by:

1. Submitting a support ticket from the PALCSchool login page (underneath the fields for username and password, there is a note that reads, “Problems logging in to PALCSchool? Please click here to submit a HelpDesk ticket”); or,

2. If you are able to log in to PALCSchool, ”Submit a Technology HelpDesk Ticket” is located in the “Quick Links” section which is displayed in the upper right-hand corner of the lobby page.

If you are unable to submit a request for service ticket because of your technical issues, please call toll-free 1-877-725-2785, then press Option 3 or dial extension 1616 for assistance.

Page 1 of 4 – updated 5/17/19 In all cases aside from a system-wide failure, a written excuse, outlining the reason for an absence, must be submitted online through the parent/guardian’s PALCSchool account to the Attendance Office within three days of a student’s absence. If the excuse is not submitted by the end of the third day following the absence, the absence will be unexcused.

To submit an excuse, the parent/guardian should select the “Attendance” icon on the left-hand navigation tag">bar in the PALCSchool Lobby. You will be given a menu from which to choose the reason for your child’s absence.

While the school strongly prefers for parents to submit a timely excuse for each day of absence, it is possible for parents to submit one excuse for multiple consecutive days of absence. However, the Attendance Office must receive an excuse no later than three days after each absence. [Example: a student is absent Monday, Tuesday, and Wednesday. An excuse for the Monday absence is due by Thursday, even though an excuse for the Wednesday absence is not due until the following Monday.]

Additionally, parents of students missing more than three consecutive school days due to illness must provide a note from a physician in addition to the written excuse from the parent. A doctor’s note may be submitted to [email protected].

Educational Leave of Absence Policy

A formal application and approval process is required for an Educational Leave of Absence. Applications must be submitted at least two weeks in advance of a planned trip. A maximum of 5 consecutive days of excused absences will be considered for approval by the division principal. A work plan must be completed with the student’s teachers and principal before the educational trip commences. Students are limited to one such request per year.

The principal has the right to deny a request when, in the judgment of the principal, there is a pattern of excessive absences from school or the student is in poor academic standing. The principal also has the right to deny a request for a leave of absence that would occur during the first 10 days of school, the last ten school days, or during standardized testing.

To request pre-approval for an Educational Leave of Absence, a parent/guardian should select the “Attendance” icon on the left-hand navigation bar in the PALCSchool Lobby, then select “Submit Pre-Approved Absence Request.”

Students whose parents/guardians do not formally request an Educational Leave of Absence will not be granted an extension for submission of work if they are unable to complete their schoolwork.

Cumulative Lawful Absences

Per the Pennsylvania Department of Education, a maximum of ten days of cumulative lawful absences verified by the parent/guardian (excluding absences that have been pre-approved by the principal) may be permitted during a school year. All absences beyond ten cumulative days may require an excuse from a physician.

Page 2 of 4 – updated 5/17/19 Additionally, upon the tenth cumulative lawful absence and/or unlawful absence (see below), the parent/guardian will be notified in writing by the school regarding the student’s absentee record.

A conference may be requested by school administration when a student has cumulatively missed 15 days or more.

After 20 or more days of cumulative absences, the division principal, guidance department and school administration will undertake an informal review of the student’s record, including days of absence and other factors, and a recommendation will be made regarding possible retention in the current grade for the next school year. Such a recommendation may include a failing grade and/or no course credit for impacted courses. If the principal and Director of Academics support the recommendation, the parent/guardian shall be notified in writing of the consequence. The decision of school administration is final.

Unexcused and Unlawful Absences Act 138 of 2016 relates to truancy and habitual truancy; it requires cyber charter schools to maintain attendance policies designed to accurately determine when a child enrolled in the cyber charter school has an unexcused absence. Unexcused absences are reported to the PDE through the Pennsylvania Information Management System (PIMS).

Absences that are not recognized as acceptable under the Pennsylvania School Code, or are lacking documentation, are considered unexcused and unlawful. This includes, but is not limited to, absences where a written excuse is not submitted within three days of the student’s absence.

Upon the third unexcused and unlawful absence, a letter will be sent from the Director of Academics (or designee) to the parent/guardian. This letter is known as a First Offense Notice, per the Pennsylvania Department of Education.

If the child continues to be truant and incurs additional absences after this notice has been issued, the school will offer the student and parent the opportunity to attend a student attendance improvement conference.

Upon the fifth unexcused and unlawful absence, PALCS shall request a conference to discuss the cause of the child’s truancy and develop a written School Attendance Improvement Plan (SAIP) to resolve truant behavior. Issues to be reviewed at the school/family conference include the appropriateness of the child’s educational environment, current academic difficulties, physical or behavioral health issues, and family/environment concerns. At the end of the conference, or in the absence of a conference, a comprehensive SAIP will be developed. All parties, including the school representative, the child, and the parents and/or family, will be given the opportunity to participate, agree to, and sign the SAIP.

If a child accumulates six unexcused absences, he or she is considered by the state to be habitually truant.

For habitually truant children under fifteen years of age, the school will refer the child to either: (a) a school- or community-based attendance improvement program; or, (b) the county Children & Youth Services (CYS) agency for services. Additionally, the school may file a citation against the parent of a habitually truant child under the age of fifteen in magisterial district court. Page 3 of 4 – updated 5/17/19 For habitually truant children fifteen years of age and older, the school will either: (a) refer the child to a school- or community-based attendance improvement program; or, (b) file a citation against the student or parent in magisterial district court. If the child continues to incur absences or refuses to participate in a school- or community-based attendance improvement program, the school may refer the child to the county Children & Youth Services (CYS) agency for services.

Students who have not complied with compulsory attendance requirements (including the SAIP) and have met the maximum truancy of 10 consecutive unexcused absences will be withdrawn from PALCS and the school district of residence will be notified.

Special note about students who transfer to PALCS during the school year with an excessive number of absences: Students who enroll in PALCS during the school year who bring with them an excessive number of absences, as determined by PALCS administration, will be automatically enrolled in a School Attendance Improvement Plan (SAIP). The SAIP will clearly state the number of absences permitted, the likelihood of grade level retention, and whether or not the student will be required to attend additional programs such as a Summer Program (summer school).

Academic Non-participation The Pennsylvania Leadership Charter School designates a classification of Academic Non-participation for students who log in for attendance purposes but are not working or completing work in their courses. This designation is separate from the unexcused and unlawful absences outlined above.

All students are required to not only log in to school each day but also to remain current with school work and assignments.

“Current” is defined by actively participating and submitting work assignments on time. When students are not actively participating in their online classes and/or are not submitting assignments by the due date or progress check, they are considered to be a non-participant in the academic environment.

Additionally, some students are required to participate in “live” virtual lessons/sessions. Students who do not attend these required sessions may accrue academic penalties.

At the discretion of the school’s division principal, guidance and academic team, students designated as Academic Non-participating will follow a process designed by the school to engage the student in the learning environment. This process includes: 1) establishing parent contact; 2) providing support through the guidance department; 3) mandatory participation in a PALCS Eagles, Bridge to Student Success Program (BtSS), or Student Opportunity for Academic Recovery (SOAR) program. These programs offer comprehensive supports for students and families who are struggling in the cyber environment.

If the aforementioned process is found to be ineffective by the school’s division principal, guidance and academic team and the student is still considered to be Academic Non-participating, the school will report all such incidents to outside agencies, such as Childline, to provide families and students with additional support beyond the capacity of the school.

Page 4 of 4 – updated 5/17/19 PA Leadership Charter School 1332 Enterprise Drive West Chester, PA 19380

Instructional Property / Acceptable Use Policy

PALCS provides a computer device for each student to enable access to the many tools needed for attending PALCS, including access to PALCS’ internet-based learning platforms, online libraries, curriculum, and other educational tools. This document serves to inform students and Parents/Guardians of school policy regarding devices and instructional materials issued by the school. Included are usage guidelines, financial responsibilities, and policy regarding wireless internet connection.

Internet Safety - It should be clear that students may find ways to access materials available through the Internet that are inappropriate, illegal, defamatory, inaccurate, or offensive. While the school will take measures to make it more difficult, the responsibility for enforcing standards of behavior on the Internet lies with Responsible Party (Parent/Guardian). Please feel free to contact the school with questions concerning safe internet usage.

I. PALCS Provided Technology A. PALCS Equipment. PALCS will provide a laptop or desktop computer and printer along with software applications needed to fulfill all of the requirements set by the school program. Students at certain grade levels and in certain programs may be issued a tablet computer upon enrollment and/or during the course of a school year. Device loaners can be provided for extenuating circumstances for an agreed upon time in addition to your primary PALCS computer. Devices that are loaned must be returned within 30 days of the allocated expiration period. B. Software. The installation or removal of software not approved in advance by PALCS is strictly forbidden. Costs related to damage caused to computers or other devices due to unauthorized use are solely the obligation of Responsible Party. C. Non-Adherence. Students who jeopardize or sabotage their own or other students’ education by causing persistent technical issues that stem from the non-adherence to this Contract will be subject to disciplinary action or expulsion. D. Substitutions. PALCS reserves the right to substitute or change these provided technologies at any time at its sole discretion. E. Ownership. Any equipment issued by PALCS is the sole property of PALCS. Under no circumstances are students and/or families permitted to remove desktop computer equipment from the student’s place of residence or keep any equipment following withdrawal or graduation from the school without a contract agreement. Any issues surrounding equipment not returned to the school will result in withheld reimbursements to the Parent/Guardian and/or will be directed to the proper legal authorities. Responsible Party agrees to pay replacement fees for materials that are not returned.

II. Equipment Delivery, Setup, and Return A. Equipment Shipment. All equipment will be shipped from an authorized provider or from the school itself to the current primary or specified shipping address of the student as listed on the enrollment form. Serial numbers of all equipment are recorded and tracked to ensure that the correct equipment is returned to the school following replacement, withdrawal or graduation. B. Boxes, Packing Materials, Instructional Manuals. It is Responsible Party’s sole obligation to retain all boxes, packing materials, instructional manuals, contact lists, and any other materials included with the shipment of devices. In the event the original boxes/packing materials are not available at the time equipment return to PALCS is necessary, it is Responsible Party’s sole obligation to obtain boxes and approved shipping materials as described in the following section. C. Packaging Materials. The original packing materials mentioned in Item B above are “critical” when utilized to return equipment. Items returned utilizing other containers/boxes must meet the standards of UPS packaging requirement which is a “double wall strength standard.” This type of container helps to ensure that the items returned are in a reusable, non-damaged condition. The boxes must also be packed with peanuts or foam that protects the contents from being smashed or broken during the shipment process. Please keep in mind that Responsible Party mentioned within this document is liable for the replacement cost of all damaged items. D. Set-up. Responsible Party is responsible for the set-up of the device when it arrives at the home. The devices will be shipped with instructions on how to set up the equipment to the school specifications. Included will be Page 1 of 4

telephone contact information for assistance in setting up the equipment. In the case of any malfunction or other issues affecting the proper use of the equipment, Responsible Party should report the issue immediately to the contact person as designated on the information sheet included with the equipment shipment. If the issues are not resolved within two (2) business days, Responsible Party should report this information to the school office of student services so that alternate arrangements can be made. E. Return of Equipment. Equipment must be returned to the school in its original boxes with original packing materials or in approved packing containers/boxes immediately upon equipment replacement or withdrawal or graduation from PALCS. This includes all parts such as keyboard, cables, wires, software, mouse, webcam, headset, and any other hardware or software provided to the student during the course of his/her enrollment in the school. Responsible Party agrees to pay repair or replacement fees in the event that the hardware is not returned to PALCS, lost, or damaged while in the possession of the Responsible Party. Should the account become delinquent, Responsible Party agrees to pay collection costs and/or reasonable attorney fees.

III. Textbooks and other Instructional Materials A. Textbooks and Instructional Materials. Should any materials be received from PALCS in damaged condition, it is the sole obligation of Responsible Party to notify PALCS immediately. At no time does ownership of the materials designated for return transfer from PALCS to student. Responsible Party shall be liable for loss or damage to any instructional materials until received by PALCS. All textbooks and textbooks with accompanying CDs must be returned in original case and in same condition as received (other than normal wear and tear). Responsible Party will take all reasonable precautions to protect materials from damage or loss. Loss and/or significant damage must be reported to PALCS within forty-eight (48) hours of occurrence. PALCS reserves the right to substitute Textbooks and instructional materials where necessary. B. Consumables. PALCS will provide, upon request, one black ink cartridge per student each school year. PALCS will not provide paper, markers, crayon, replacement ink cartridges, or other consumables used in the ordinary course of education. These consumables are solely the obligation of Responsible Party to provide. C. Boxes and Packing Materials. It is Responsible Party’s sole obligation to retain boxes and packing materials included with the shipment of books and other instructional materials. In the event the original boxes/packing materials are not available at the time such materials are to be returned to PALCS, it is Responsible Party’s sole obligation to obtain boxes and shipping materials.

IV. Lost, stolen and damaged equipment A. Insurance. Responsible Party agrees to maintain, at his or her expense, adequate insurance to cover damage, loss, theft, vandalism, or any other cause that results in loss or damage to the PALCS equipment to its full replacement value. Responsible Party agrees to be financially liable for the equipment regardless of any insurance proceeds. B. Hardware or Software Issues. PALCS will repair hardware and software issues that have occurred during normal use such as a hard drive failure or operating system crash. The device must be shipped (pre-paid shipping labels are provided) or dropped off for repair in the original packing materials to the following address (an appointment is necessary to drop off/pick up a laptop): Attn: Shipping/Returns Department, PA Leadership Charter School, 1332 Enterprise Drive, West Chester, PA 19380. When a school device is being repaired by PALCS the Parent/Guardian is responsible for providing/locating an alternate computer, with an internet connection, for their student to complete his/her schoolwork. It may take as much as 4 weeks to repair a device. C. Equipment damage/loss/theft. Responsible Party must notify PALCS within 48 hours of the occurrence or discovery of any theft, damage, destruction or other loss of any school-owned equipment. Responsible Party is responsible for the cost of the equipment (up to $1000.00 to replace/repair). In most cases, Responsible Party will file a claim with his/her homeowner’s insurance carrier, and PALCS will assist this process by submitting all of the information related to the cost of the equipment. Responsible Party must immediately forward to PALCS Asset Recovery Department copies of all police reports, fire reports, insurance claims and any other applicable reports. If adequate security precautions were in place, and all appropriate documents have been provided to PALCS, then Responsible Party will not be liable for replacing the item(s). However, if the appropriate documents are not provided or PALCS determines that the damage/loss was a result of careless actions, Responsible Party will be billed the replacement value of the item(s). Should the device need repair, and the Responsible Party is able to have the device serviced by a certified non-PALCS tech, documentation noting the tech certification and the price of the repair must be reported to PALCS prior to such action. Permission by PALCS can then be given for such outside repairs to proceed. In the event a device has been neglected, damaged (exception of normal wear and tear), or lost, PALCS will assess the student’s device privileges and make a determination with regards to replacement device(s). This may include issuing a student a variety of different computer models. This includes, but is not limited to, a desktop computer or an all-in-one desktop.

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D. Intentional/Unintentional Damage, Neglect, Environmental Contamination. Responsible Party is to make every effort to protect PALCS equipment from damage (whether intentional or unintentional), neglect, and environmental contamination so that returned equipment may be re-used. Responsible Party is solely responsible for the cost of repairing and/or refurbishing and, if necessary, replacing such damaged equipment.

V. Internet/Phone Services Internet services will be provided to every student/household. Responsible Party may choose to use any internet service carrier available to them. The school recommends a high-speed direct connection (via Ethernet cable) to provide the optimum online learning connection. Other connections may be insufficient for some aspects of online education; an inadequate connection is not an acceptable excuse for incomplete school assignments. Assistance in choosing an internet service company is available from the IT Department of the school.

VI. Technical Support These support services will be provided only for students of the school and concerning issues related to school equipment. No services can be provided to those outside of the school or for the personal equipment of the student or his/her family or friends, including wireless (WiFi) systems. Use of support services for non-school issues, equipment, software, or other matters is a violation of this agreement, and violators will be subject to disciplinary action by the school. Support is provided by the staff of the IT HelpDesk at the school. They can be reached by submitting a HelpDesk ticket at http://support.palcs.org or by calling 610.701.3333 ext. 1616. . A. Wireless Internet. 1. Laptops and mobile devices enable students to access the many tools needed for attending school, including access to PALCS’ internet-based learning platforms, online libraries, curriculum, and other educational tools and materials. Laptops are wireless capable and can be used with a wireless network for most school work. 2. However, PALCS cannot support wireless (WiFi) because every home wireless router has a unique configuration and a wired connection is preferred for some course content. PALCS recommends using an Ethernet cable to connect to the Internet when your student is participating in live online lessons, taking assessments and tests, streaming video, and to ensure the device receives necessary security and classroom updates (once a week). We ask that before contacting the HelpDesk for a technical issue a laptop must be connected to the Internet via a wired connection using an Ethernet cable. PALCS provides a 50’ Ethernet cable if needed upon request to facilitate this requirement.

VII. Acceptable Use A. Appropriate Use by Students. Students are responsible for behaving in an appropriate manner on the school’s computer, just as if they were present in a traditional classroom or school-sponsored event. The school may suspend or expel any student behaving inappropriately. B. Personal Responsibility. The student is personally responsible for his/her actions in accessing and using the school’s computer resources. Students are advised never to access, store, keep, or send anything they would not want their parents/guardians, teachers, or school administration to see. All communications in the school are logged and available for review by school-authorized personnel, and communications over the Internet are often public in nature. Computer storage areas may be treated like the traditional school locker, the contents of which may be reviewed by school administrators to ensure that students are using the computer system responsibly. Content deemed inappropriate will be confiscated and, if called for, turned over to the appropriate authorities. 1. Software. Students should never download or install any commercial software, shareware, or freeware onto their computer unless they have written permission from a staff member at PALCS. 2. Inappropriate Behavior. Students should not use profane, abusive, or impolite language when communicating online. They should not access any materials that are in violation of school rules and policies. If a student encounters such material by accident, he/she should report it to his/her parents/guardians immediately. Students will restrict their access to material deemed inappropriate by staff and parents/guardians. 3. Conduct. Students will use appropriate conduct toward others. 4. Copyright/License Agreements. Students will observe and respect copyright and license agreements. 5. Passwords/Personal Information. Students will keep passwords and personal information confidential. Students are expected to respect the computer privileges given to them. All students must keep their passwords to themselves. Students and Parents/Guardians are prohibited from

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using another student or Parent/Guardian's passwords or accounts. Students are prohibited from breaking into ("hacking") other files or systems, downloading copyrighted material, or conducting a personal business enterprise using the school computer network. 6. Proper Use. All use of computer technology must be related to or in support of the educational goals of the student as stated by the school. 7. Illegal Activity. The use of the Internet and/or computer technology for any illegal activity including, but not limited to, gambling, advertising, spamming, sending offensive materials, spam mail, discriminating remarks, or obtaining pornographic or other obscene material is strictly forbidden. The use of the Internet and computer technology for fraudulent or illegal copying, communication, taking or modification of material is strictly forbidden. Such action will be referred to the federal authorities. 8. Right to Remove. PALCS reserves the right to remove any student violating these or other school policies to prevent further unauthorized activity and to protect other students, staff, and property.

VIII. Responsibility. Responsible Party must monitor his/her student’s compliance with this contract. Violation of this contract may result in disciplinary action which may include suspension or expulsion.

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PA Leadership Charter School 1332 Enterprise Drive West Chester, PA 19380

EXPECTATIONS OF THE PARENT/GUARDIAN

The Parent/Guardian is an integral part of each student’s success and a key partner with the school. Each student is required to have a Parent/Guardian facilitate at home to ensure that the student is attending regularly and completing assignments on time. The Parent/Guardian is an essential partner with the teacher, the student, and the school. A Parent/Guardian’s responsibilities for facilitating at home may vary with age and motivation of the student. Students in primary grades (K-8), students with lower motivation levels, and students with special needs generally require more direct involvement in the learning process. The PALCS model of education requires a commitment that goes beyond a traditional public school.

Primary Responsibilities of the Parent/Guardian:

 Provide a safe and secure environment which requires that the student has adult supervision during the entire school day to meet health and safety regulations.  Maintain an active internet account so that the students can complete online assignments.  Maintain timely communications with teachers, principals, counselors, and school officials. o Respond promptly to all school communication (within 24 hours). o Parent electronic communication is to be sent through the Parent/Guardian e-mail account.  Maintain confidentiality of Parent/Guardian username and password access.  Ensure that the student completes the Onboarding Course prior to accessing courses.  Ensure that the student is attending school as per our attendance policy. Parent/Guardian may not log into the student’s account for attendance purposes without the student present. Students of compulsory school age, who have not complied with compulsory attendance requirements and are consistently truant, may be withdrawn from PALCS and referred back to their school district of residence.  Ensure that the student is an active participant in school and is completing work in all courses as assigned. o Expect to spend four (4) to six (6) hours per day engaged in school work and virtual lessons. o Monitor student progress by checking online to see that assignments have been completed and submitted.  Provide parental involvement as needed.  Ensure that the student’s progress is satisfactory by checking grades on a regular basis, communicating with teachers, and attending parent-teacher conferences.  Comply with state and local testing requirements. o Ensure the student’s participation in all required state assessments. o Provide transportation for student to state-mandated testing locations, allotting time for test completion.  Complete and return annual health forms, including forms to be completed by the child’s healthcare provider, according to the child’s grade as required by School Health Services and the Pennsylvania Department of Health.  Update School Health Services via mail, e-mail, or fax with documented proof of additional immunizations received by the student.

Technological Knowledge Required of a Parent/Guardian:

The Parent/Guardian facilitating at home must have an understanding of technology to provide appropriate supervision of the student while the student is in attendance at PALCS. If the Parent/Guardian does not have a sufficient understanding of computer technology, PALCS will provide training until the Parent/Guardian serving is able to demonstrate sufficient knowledge. Basic knowledge includes, but is not limited to, e-mail, basic use of Office, applications, PALCSchool navigation, and the internet.

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PA Leadership Charter School 1332 Enterprise Drive West Chester, PA 19380

PALCS Enrollment Agreement

Before completing this form, please carefully review the following documents:

1. PA Leadership Charter School’s Expectations of the Parent/Guardian 2. PA Leadership Charter School’s Attendance Policy 3. PA Leadership Charter School’s Instructional Property/Acceptable Use Policy

Student: ______(Last Name) (First Name) (Middle Name)

I acknowledge that I have read the policies mentioned above and understand and agree with their terms.

Please initial each of the following statements:

ATTENDANCE

1._____ I have read and will comply with the PALCS Attendance Policy.

2._____ I understand that school attendance must be logged online each school day and that remaining current with all assignments is required in order to be counted as “present.”

3._____ I understand my student might be required to participate in synchronous classes or learning assignments (synchronous – instructors and students are online at the same specified time). Students who do not attend these required classes may incur attendance and academic penalties.

4._____ I understand, as a parent, I am responsible for providing the attendance office with verification of the reason for each of my student’s absences.

5._____ I understand that in the event my student must be absent from school for an extended period of time for education/health reasons, the absence must be approved by PALCS administration prior to the extended absence.

6._____ I understand attendance is essential to the success of my student. Therefore, the accumulation of unexcused absences may result in truancy action.

INSTRUCTIONAL PROPERTY/TECHNOLOGY

1._____ I have read and will comply with the PALCS Instructional Property/Acceptable Use Policy.

I understand that I am responsible for thecareand security of all PALCS-issued 2._____ equipment, including laptop/desktop computer, printer, and any other hardware or software. I understand that I am financially responsible for any school property that is provided to my student, including property that has been damaged, is moved to another location, or is not returned when requested by the school.

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3._____ I will retain original boxes and packing materials associated with PALCS equipment and textbooks.

4._____ I understand that it is my responsibility to secure and maintain internet service for the duration of my student’s enrollment at PALCS.

5._____ I understand that reimbursement for internet will be withheld until all PALCS equipment, materials, and textbooks have been returned upon replacement, graduation, or withdrawal from PALCS.

6._____ I understand that students are responsible for behaving in an appropriate manner on the school’s computer, just as if they were present in a traditional classroom or school-sponsored event. The school may suspend or expel any student behaving inappropriately.

GENERAL

1._____ All of the information I have provided to PALCS for enrollment is accurate. I understand that I am responsible for reviewing this information and will communicate any changes to PALCS.

2._____ I understand as parent/guardian, signing this form will provide me with access to PALCSchool and that I must abide by its terms of use, specifically the Acceptable Use Policy as outlined in the PALCS Parent/Student Handbook.

3._____ I understand that both my student and Iarebound by the terms of the PALCS Parent/Student Handbook.

4._____ I understand that studentsingrades3,4,5,6,7,and 8arerequired to participate in the Pennsylvania System of School Assessment (PSSA). In addition, I understand that my student is required to take Keystone exams on the scheduled dates indicated by the Pennsylvania Department of Education. All of these assessments will require travel to a face-to-face testing site near my student’s place of residence.

5._____ I understand that if my student does not attend the day of scheduled state assessments, this absence will be documented as an unexcused/illegal absence.

Parent/ Guardian: ______(Last Name) (First Name) (Middle Name)

______(Signature) (Date)

Parent/ Guardian: ______(Last Name) (First Name) (Middle Name)

______(Signature) (Date)

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PA Leadership Charter School 1332 Enterprise Drive West Chester, PA 19380

Family Income Form for the 2019-2020 School Year

PLEASE NOTE: The Pennsylvania Department of Education (PDE) requests that all schools under its jurisdiction collect information on a yearly basis regarding the total family income for all of their students. This information is collected by the PDE for the express purpose of providing additional funding to schools for supplemental services to students at risk of academic failure in reading, mathematics, and/or science. These supplemental services are beneficial to many students attending PA Leadership Charter School, and the funding that we receive is directly tied to the completed forms that are returned to us.

As you can see on page 2 of this form, total family income levels are divided into several possible ranges of dollar amounts so it is not necessary to list a specific amount. Please be assured that the information you provide on this form is kept confidential, and family names are not shared.

The PDE requests that we update this information every year so you will receive a new form each year to complete and return to us. Thank you for your cooperation.

Student Information (Please type or print)

List only those students enrolled in PALCS.

First Name, Last Name Birth Sex Grade School District of Residence Indicate if Child is a Foster Child, Ward Date (where you live) of Court, or Food Stamp Recipient

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Calculating Household Income Family Annual salary range – Please check one. Size Include all income for all household members (include one  $0 to $16.237  $16,238 to $23,107  $23,108 and above yourself, all children in the home, your spouse, grandparents, and all others related and unrelated in your household). two  $0 to $21,983  $21,984 to $31,284  $31,285 and above Below is a list of income to report.

Earnings from work: wages/salaries/tips, strike benefits, three  $0 to $27,729  $27,730 to $39,461  $39,462 and above unemployment compensation, worker’s compensation, or net income from self-owned business or farm. four  $0 to $33,475  $33,476 to $47,638  $47,639 and above

five  $0 to $39,221  $39,222 to $55,815  $55,816 and above Other Income: disability benefits, interest dividends, cash withdrawn from savings, estate/trusts/investments, net royalties/annuities/net rental income, or regular contributions six  $0 to $44,967  $44,968 to $63,992  $63,993 and above from person(s) not living in household. seven  $0 to $50,713  $50,714 to $72,169  $72,170 and above Public Assistance/Child Support/Alimony: public eight  $0 to $56,459  $56,460 to $80,346  $80,347 and above assistance/welfare payments or alimony/child support payments. nine  $0 to $62,205  $62,206 to $88,523  $88,524 and above Pension/Retirements/Social Security: pensions, supplemental security income, retirement income, and Social ten  $0 to $67,951  $67,952 to $96,700  $96,701 and above Security.

Certification and Signature

I certify that all of the above information is true and correct and that all income is reported. I understand that this information is being given for the receipt of federal funds and may require verification.

Parent/Guardian Signature:______Date:______

Parent/Guardian Print Name: ______

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PA Leadership Charter School 1332 Enterprise Drive West Chester, PA 19380 [email protected] 610.701.3333 ext. 1030 Fax: 610.701.3339

Request for Reimbursement for Internet Service

In order to receive Internet reimbursement, the following items must be returned to PALCS, Attn: ISP Reimbursement, 1332 Enterprise Drive, West Chester, PA 19380.

I. Reimbursement Request At the beginning of every school year the following items must be completed and returned to PALCS: A. The completed and signed Internet Service Provider (ISP) Request for Reimbursement Form. B. A complete, itemized copy of your Internet connection bill. The bill must include the preprinted name and address of the person being billed and all accompanying detailed pages. C. All requests for returning students must be received by October 31. Requests from new enrollments are accepted throughout the school year. The reimbursement cycle will begin upon receipt of a copy of the Internet connection bill for the first full month of the student’s enrollment.

II. Deadline for Reimbursement The cut-off date for qualifying for a month of reimbursement will be the 15th of each Month. For example: A. If a student enrolls before the15th of the month, his/her Internet connection will qualify for reimbursement for the month. B. If a student enrolls after the15th of the month, his/her Internet connection will not qualify for reimbursement for the month.

III. Changes to Student Internet Services All service changes during the school year, including address, billing name, and rate changes, must be reported to the ISP Reimbursement Department. When a new bill is received, please resubmit a copy to the ISP Reimbursement Department. Failure to report these changes could result in a delay of receiving your reimbursement.

IV. Reimbursement Schedule Reimbursement will be administered two times throughout the year: A. September-December: reimbursed in the Spring. B. January-June: reimbursed in the Fall. To receive reimbursement, all books and other PALCS property must be returned for the year. C. Reimbursement will be made for the current school year only. PALCS does not reimburse for Internet service during the months of July and August.

V. Reimbursement Connections It is recommended that all students have access to a basic high speed line to provide the optimum online learning connection. A. High-Speed: PALCS reimburses one Internet connection per family for basic high speed/DSL charges only. (DSL: high-speed Internet connection through the phone line. Cable: high-speed connection through a cable company.) B. Dial-Up: If necessary, dial-up service is provided through a PALCS provider. For further details, please contact a PALCS representative. C. Wireless: wireless internet providers (such as mobile phones, wireless USB broadband cards, or satellite) are not compatible with PALCS’ curriculum and computer configuration.

VI. Reimbursement Amounts Reimbursement will be paid only on the basic Internet high speed/DSL charge. PALCS reserves the right to determine the basic reimbursement amount from the submitted bill in accordance with the available service area rates. This information will be compiled from Pennsylvania Internet Service Providers. Newly enrolled students may also qualify for additional reimbursements:  Set-up fees for Internet access incurred by families who do not have service. (PALCS reserves the right to determine the reimbursement amount from the submitted bill.)  Installation of Ethernet cable to be run by the ISP provider to the student’s workstation. (Receipt for this service must be submitted for reimbursement. Maximum reimbursement: $150.00)

Additional charges will not be reimbursed by PALCS: The following charges will not be paid by PALCS: enhanced high speeds and service packages that are not described above or necessary for education; enhanced featured lines; taxes, surcharges and fees; rental or purchase of equipment, modem or router; wire maintenance; Internet security; and late fees, reconnection fees, etc., that are not incurred as a result of PALCS action or inaction and/or that are not in any way connected with required courses or the provision of education to students.

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Pennsylvania Leadership Charter School ISP Request for Reimbursement Form

Reminder to Qualify for Reimbursement the following paperwork must be filed with the ISP Department:

A. Completed ISP Request for Reimbursement Form. B. Complete, itemized copy of your Internet connection bill. The bill must include the preprinted name and address of the person being billed and all accompanying detailed pages. C. All changes to your service must be reported immediately and a new bill submitted. There will be no reimbursement for contracted services incompatible with PALCS policy without prior approval.

Student Information: (only one form per family is needed)

Student(s) Full Name(s): ______Date: ______Address: ______Home Phone Number: ______

Internet Provider Information: Internet Service Provider Name: ______

Type of Connection: Cable DSL Fiber Other______

Bill Information: Reimbursement will be made to the same person and address as appear on the invoice submitted.

Name on Invoice: ______Address on Invoice: ______**Please attach a copy of a current bill. ISP reimbursement will only be paid with a current bill.**

Signature: ______

Opt-out of ISP reimbursement

I understand by signing this section I’m electing not to be reimbursed for my internet service. All other fields on this page must be left blank, if this section is signed.

Signature ______Name ______

New Student must submit all paperwork within 60 days of enrollment. Returning students must submit paperwork by October 31st, 2019.

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PA Leadership Charter School 1332 Enterprise Drive West Chester, PA 19380

PA Leadership Charter School Home Language Survey

ALL newly registering students regardless of race, nationality, or language origin MUST complete this form. Federal law requires that all Local Education Agencies (LEAs) utilize a non-biased procedure for identifying which students are potential English Learners (ELs) in order to provide appropriate language instruction educational programs and services. Given this responsibility, LEAs have the right to ask for the information contained on this and other forms associated with the identification process.

Student Information (Parents/Guardians should complete this section):

Child’s first name: ______

Child’s family name: ______

Child’s Date of Birth: ______(Month/Day/Year)

Questions for Parents or Guardians:

1. Is a language other than English spoken in the child’s home? No Yes (language) ______

2. Does your child communicate in a language other than English? No Yes (language) ______

3. What is the language that your child first learned to speak? ______

Parent/Guardian Signature: ______

Date: ______

Interpreter Provided No Yes

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PA Leadership Charter School 1332 Enterprise Drive West Chester, PA 19380

Why I Chose PALCS

Student Name: ______

Parent/Guardian Section

What factors contributed to the decision to choose PALCS?

What do you hope your student will gain by attending PALCS?

Please list any special circumstances or difficulties which may have affected the educational progress of your student.

Student Section

What is your favorite class? Please explain why you enjoy it.

Please share your interests, hobbies, or talents.

What extracurricular activities or community organizations do you participate in?

Describe an accomplishment of which you are proud.

If Parent/Guardian helped the student complete this section, please indicate with initials: _____

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PA Leadership Charter School 1332 Enterprise Drive West Chester, PA 19380

RELEASE OF DIRECTORY INFORMATION AND PERMISSION FOR TEXT MESSAGING

DIRECTORY INFORMATION

The primary use for directory information by Pennsylvania Leadership Charter School is to include this type of information in certain school publications. It is generally not considered harmful or an invasion of privacy if released. Examples of school publications include but are not limited to:

 A playbill or program  Annual yearbook  Honor roll or other recognition lists published at school or in newspapers  Graduation programs

Please Check One:

I hereby give permission to publish my child’s directory information in school publications for only those reasons that Pennsylvania Leadership Charter School deems appropriate.

I do not give my permission to have my child’s directory information published or used in any way.

TEXT MESSAGING

Please Check One:

I hereby give permission to allow my child to communicate via text messages with teachers and staff members of the Pennsylvania Leadership Charter School. This communication will solely pertain to educational matters; for example, missing assignments, course work questions, etc.

I do not give my permission to teachers or staff members at Pennsylvania Leadership Charter School to communicate with my student via text messaging.

______Printed Name of Student

______Printed Name of Parent/Guardian

______Signature of Parent/Guardian Date

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PA Leadership Charter School 1332 Enterprise Drive West Chester, PA 19380

STATE-MANDATED TESTING Agreement Form

______Student Name

I hereby certify that I accept the responsibility of taking the above-named student to whatever location is deemed necessary and appropriate by PA Leadership Charter

School for the purpose of State-mandated testing including, but not limited to, PSSA and Keystone Testing.

I further certify that said student will arrive at that location before the official starting time on all assigned days.

Signed and Certified:

______Printed Name of Parent/Guardian

______Signature of Parent/Guardian Date

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PA Leadership Charter School 1332 Enterprise Drive West Chester, PA 19380

PHOTO/VIDEO RELEASE OPTION FOR NON-DISCLOSURE

At PALCS, we respect the privacy of all of our families. To build and sustain a sense of community, we offer all students the opportunity to participate in school functions which may include video and/or photography. Some of these events include field trips, school-wide picnics, moving-up ceremonies, and division level special events. It is our intent to only videotape or photograph these events for our own use at the school.

Additionally, some events require disclosure of a student’s name. Events such as graduation, the 5th & 8th grade moving-up ceremonies, playbills, University Scholar publications, division level newsletters, and school-wide recognition of student achievement are all examples of the publication of a student’s name within the PALCS organization.

Every effort will be made to exclude students who do not wish to be recorded from recording during school events. However, please note that, even with a non-disclosure in place, if a student is shown participating in school activities that are open to the public or if the student’s image is incidental or captured only incidentally as part of the background, the school will not be held responsible for such inadvertent recording.

Please also note that high school graduation is a live-streamed event that is typically shared on YouTube.

Options for Use of Photo or Videos for the Current School Year

Student Name: ______

Student Grade: ______

Name of Parent/Guardian: ______

□ I hereby grant permission to PALCS to use photographs or video footage of the above- named student within the context of the PALCS Photo/Video Release Policy (above).

OR □ I hereby request PALCS NOT use photographs or video footage of the above-named student in the following school materials:

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□ Special recognition (such as Honor Roll status)

□ PALCSchool event and activity coverage

□ PALCS public website (www.palcs.org)

□ PALCS-sponsored social media

□ Print materials (brochures, flyers, et. al.)

I understand that this request will remain in effect for the current school year. I also understand that this request will not prohibit the use of photos and/or videos in student-produced materials (such as yearbooks, school newspapers, et.al.) Every effort will be made to exclude students who do not wish to be recorded from recording during school events. However, please note that, even with a non-disclosure in place, if a student is shown participating in school activities that are open to the public or if the student’s image is incidental or captured only incidentally as part of the background, the school will not be held responsible for such inadvertent recording.

Signature of Parent/Guardian: ______

Date: ______

Page 2 of 2

Pennsylvania Leadership Charter School

2019-2020 School-Parent Compact

In accordance with the Elementary and Secondary Education Act (ESEA), the School-Parent Compact outlines agreed-upon responsibilities of The Pennsylvania Leadership Charter School staff, parents, and students participating in activities, services, and programs funded by Title I, Part A (a Federal Grant), that will help children achieve academic success. The Pennsylvania Leadership Charter School values each parent as an integral partner for students to reach and exceed the Pennsylvania State Department of Education’s high academic standards. Collaboratively, parents and school staff build, maintain, and work within a vital partnership to provide an exceptional student learning experience.

School’s Responsibilities: The Pennsylvania Leadership Charter School will: ● Provide high-quality curriculum and instruction in a supportive and effective learning environment. ○ Curriculum is reviewed and revised for alignment on an ongoing basis. ○ Instruction is based on best practices to meet the needs of all learners. ○ Teacher training and professional development opportunities are provided for and offered to instructional staff. ● Provide opportunities for ongoing communication between parent and teachers. ○ Reasonable access to staff through phone calls, virtual meetings, office hours. ○ Parent teacher conferences are held twice a year and on-demand, as needs arise. ○ Written communication - announcements, newsletters, email, instant messaging. ○ Frequent reporting of student academic progress - progress reports, report cards. ● Provide assistance in understanding academic achievement standards, assessments, and how to monitor your child's progress. ○ Parent informational and planning meetings, back-to-school nights, open houses. ○ Parent training sessions and posted parent resources. ● Provide activities that interest and engage students to be involved in the learning community.

Parent’s Responsibilities: We, as parents, will support our children’s learning in the following ways: ● Provide a safe and secure learning environment. ○ Be sure each student has adequate adult supervision during the school day for the student to complete his or her work in a safe, supportive, and healthy manner. ● Ensure that your child has reliable internet access, attends school daily, and participates actively in all courses.

Page 1 of 2 SPC 19-20 - revised 5/17/19 ○ Regularly review your child’s school work. Check to make sure assignments are completed and submitted on time in all courses. ● Attend parent conferences and participate in parent informational meetings. ● Encourage positive use of extracurricular time and monitor online behavior.

Student Responsibilities: We, as students, will share the responsibility to improve our academic achievement by: ● Attend school daily, engage in coursework, and complete assignments by due dates. ● Actively participate in school activities, virtual lessons, and academic/social support such as student government, elections, self-government, fundraisers, drives, virtual activities and events, newsletter, trips, S.A.D.D. events. ○ Student Government will provide student perspective on inclusive extra-curricular activities such as Creative Writing Circle, Book Society, GSA.

Thank you for your engagement in your child’s education. Please review this School-Parent Compact with your child/ren as it may be discussed further with you by staff as it relates to your child’s school progress. Contact Ms. Zofia Swiatek, Federal Programs Coordinator, to request more information by phone #1-610-701-3333 x1108 or email [email protected]. Your signature indicates that you and your child/ren read and understand this compact.

Student Name(s) (Please print) ______

Student Signature ______

Parent/Guardian Name (Please print) ______

Parent/Guardian Signature ______

Date ______

Page 2 of 2 SPC 19-20 - revised 5/17/19

Office Use Only: School ID# ______

PALCS Health Services Tammy Swink, School Nurse 211 Carter Drive, Suite C West Chester, PA 19382 Phone: 610-430-6525, ext.1242 Fax: 610-692-2783 School Health Information e-mail: [email protected]

Name of Child: ______DOB:______Street: ______City:______Zip:______Home Phone: ______Cell Phone: ______Sex: M F Grade: ______

The School Health Act requires that Physical Examinations for new students in K or grade 1 and students in grades 6 and 11 be provided to schools. If you prefer for the physical exam to be done by your family doctor, a Private Physical form is available for completion by your child’s physician. Completed copies must be returned to the school nurse.

The School Health Act also requires that Dental Examinations for new students and students in grades K, 3, and 7 be provided to schools. If you prefer for the dental exam to be performed by your family dentist, a Private Dental form is available for completion by your child’s dentist. Completed copies must be returned to the school nurse. ***If you choose to have your child evaluated by the school physician/dentist, you will be contacted with available exam dates. NO IMMUNIZATIONS WILL BE ADMINISTERED DURING SCHOOL PHYSICAL EXAMS.

ꞏ For new students entering K or Grade 1 and students going into grades 6 and 11, I prefer to have my child examined by: Our Family Doctor West Chester School Doctor

ꞏ For new students entering K or Grade 1 and students going into grades 3 and 7, I prefer to have my child examined by: Our Family Dentist West Chester School Dentist

Does your child wear glasses? Yes No Contacts? Yes No

Does your child have a hearing problem? Yes No Hearing aid? Yes No

Does your child have allergies? Yes No If YES, please list (i.e. insects, bees, food, environment, medications, etc.) ______Does your child have asthma or reactive airway disease? Yes No

Is your child taking any medications? Yes No If YES, Please list below:

 Non prescription______ Prescription______ Reason for medication______Has your child ever had seizures? ______Date: ______Cause: ______

Does your child have any special health needs or problems? Yes No If YES, please explain: ______

Has your child ever had a serious operation, illness, accident or concussion? Yes No Date: ______If YES, please explain:______

Has your child had: Disease /Date Disease/Date Disease/Date Please and, Chickenpox Mumps Hepatitis if possible, Measles Scarlet Fever Tuberculosis provide dates Whooping Cough Rheumatic Fever German Measles

* Please send dates of newly administered immunizations so that we can update your child’s health record.

Parent/Guardian Signature:______Date:______

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PA Leadership Charter School 1332 Enterprise Drive EMERGENCY CARE INFORMATION FORM West Chester, PA 19380

2019-2020 School Year Phone: 610.701.3333 Fax: 610.701.3339 www.palcs.org

______M___ F______Student’s Last Name Student’s First Name M.I. Grade Gender DOB

Street: ______City:______Zip:______Home phone:(_____)______

Child Lives with: Both Parents Parent 1 Parent 2 Guardian Other______

Parent 1’s name:______Primary Phone: (___)______Alternate Phone: (___)______

E-mail: ______

Parent 2’s name:______Primary Phone: (___)______Alternate Phone: (___)______

E-mail: ______

Guardian's name:______Primary Phone: (___)______Alternate Phone: (___)______

E-mail: ______

In case of an emergency when parent/guardian cannot be contacted, I authorize the following individuals to be notified and give them permission to pick up my child:

Name: ______Relationship:______(____)______(____)______Primary Phone Alternate Phone

Name: ______Relationship:______(____)______(____)______Primary Phone Alternate Phone

Name:______Relationship: ______(____)______(____)______Primary Phone Alternate Phone

______

In case of an emergency and it is necessary to call a physician or dentist, please contact:

______at (_____)______at (____) ______Physician’s name Physician’s phone number Dentist’s name Dentist’s phone number

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Student's Last Name: ______Student's First Name: ______

Insurance Information:

No health insurance HMO Other:______

Medicaid: (provide Medicaid number)______

Insurance Group Name:______Policy Number: ______

List any allergies: ______

EPI PEN Prescribed? YES / NO If the answer is yes, please explain the reason: ______

Please circle all that apply:

ADHD Arthritis Asthma Bleeding Disorder Cardiovascular Diabetes Type 1 or 2 (circle)

Gastrointestinal Migraines Orthopedic Scoliosis Seizure Disorder Other ______

List the names and reasons for medications your child is currently receiving:

Medication: ______Reason: ______

Medication: ______Reason: ______

Medication: ______Reason: ______

**Parents/Guardians are responsible for providing the School Nurse or designated employee with ALL prescription and/or non-prescription medications needed for their child while they attend a PALCS campus, event or field trip.

** EACH PRESCRIPTION and/or NON-PRESCRIPTION medication must be packaged in its original container and accompanied by a physician’s order. Medications must be labeled with their child's name and the dates and instructions for use. In addition, written parent authorization must accompany the medication.

STUDENTS ATTENDING USP OR CPFA: I give the School Nurse or designated employee permission to administer the following over the counter medications according to package directions if needed:

PLEASE INITIAL ALL THAT APPLY: Tylenol ______Ibuprofen ______Tums______Benadryl ______

**For life threatening allergic reactions injectable adrenaline (EPI-PEN) will be administered**

If your child requires an EPI-PEN for the treatment of a known allergy and they attend a PALCS campus or PALCS event, it is the parent/guardian responsibility to provide the School Nurse with an EPI-PEN and physician orders for usage.

In the event of a medical emergency involving the student, the Pennsylvania Leadership Charter School (PALCS) will attempt to reach the parent/guardian or one of the people listed as an emergency contact. If none of these people can be reached, PALCS personnel have my permission to use discretion in securing medical aid for my child.

It is understood that PALCS, any sponsoring district or authority, or their respective officers, agents, and employees will not be responsible for the expense incurred. Further, I agree to release and hold harmless all such parties from all causes, liabilities, damages, claims, demands or losses whatsoever related to the medical condition of the student allowed by law.

I understand and agree to the release.

Parent signature: ______Date: ______

Guardian signature: ______Date: ______Page 2 of 2

PALCS Health Services Tammy Swink, School Nurse 211 Carter Drive, Suite C West Chester, PA 19382 Phone: 610-430-6525, ext. 1242 Fax: 610-692-2783 e-mail: [email protected]

Health Screening and Immunization Requirements

PLEASE READ:  Please refer to the following chart regarding your child's health requirements for school attendance. New students entering K or Grade 1 and all students in grades 6 and 11 must provide a current physical exam.

New students entering K or Grade 1 and all students in grades 3 and 7 must provide a current dental exam.

 All students in all grades must provide annual health screenings, which may be performed at your nearest PALCS office or doctor’s office. (Height/Weight/Vision/Hearing) Please see chart below for additional screenings by grade.  Summary of Health Grades Requirements K or 1 2 3 4 5 6 7 8 9 10 11 12 Medical Exam X X X Dental Exam X X X Height/Weight X X X X X X X X X X X X Vision X X X X X X X X X X X X Hearing X X X X X Scoliosis XX

Screening results should be dated on or after 03/01/19.

Immunizations: A complete immunization record must be submitted for each student upon original entry into school. Please submit the dates of newly administered immunizations to PALCS nurses when they are received.

Required Immunizations: 4 doses of Tetanus, Diphtheria and acellular Pertussis (1 dose on or after 4th birthday) (DTP or DtaP or DT or Td) 4 doses of Polio (OPV, IPV) (1 dose on or after 4th birthday) 2 doses of MMR (measles, mumps, and rubella; 1st dose must be given on or after 1st birthday) 3 doses of Hepatitis B (properly spaced; 3rd dose may not be given before 6 months of age) 2 doses of Varicella (chickenpox) vaccine or evidence of immunity; (1st dose must be given on or after 1st birthday).

7th through 12th Grade ADDITIONAL immunization requirements for attendance:  1 dose of tetanus, diphtheria, and acellular pertussis (Tdap)  2 doses of meningococcal conjugate vaccine (MCV) (1st dose given at 11-15 years; 2nd dose required at age 16 or entry into 12th grade)

Please note: Exemptions for immunizations or health exams must be documented in the student’s school health record. Pennsylvania’s school immunization requirements can be found in 28 PA.CODE CH.23 (School Immunization). Contact your health care provider or 1-877-PA-HEALTH for more information.

*Please be advised that unvaccinated students may not be permitted to participate in class activities if there is an outbreak in the area.

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H511.336 (Rev. 9/2012) Page 1 of 4: STUDENT HISTORY PARENT / GUARDIAN / STUDENT: Private or School Complete page one of this form before PHYSICAL EXAMINATION student’s exam. Take completed form to OF SCHOOL AGE STUDENT Bureau of Community Health Systems appointment. Division of School Health

Student’s name ______Today’s date______Date of birth ______Age at time of exam______Gender:  Male  Female

Medicines and Allergies: Please list all prescription and over-the-counter medicines and supplements (herbal/nutritional) the student is currently taking: ______Does the student have any allergies?  No  Yes (If yes, list specific allergy and reaction.)

 Medicines  Pollens  Food  Stinging Insects

Complete the following section with a check mark in the YES or NO column; circle questions you do not know the answer to.

GENERAL HEALTH: Has the student… YES NO GENITOURINARY: Has the student… YES NO 1. Any ongoing medical conditions? If so, please identify: 29. Had groin pain or a painful bulge or hernia in the groin area?  Asthma  Anemia  Diabetes  Infection 30. Had a history of urinary tract infections or bedwetting? Other______31. FEMALES ONLY: Had a menstrual period?  Yes  No 2. Ever stayed more than one night in the hospital? If yes: At what age was her first menstrual period? ______3. Ever had surgery? How many periods has she had in the last 12 months? ______4. Ever had a seizure? Date of last period: ______

5. Had a history of being born without or is missing a kidney, an eye, a DENTAL: YES NO testicle (males), spleen, or any other organ? 32. Has the student had any pain or problems with his/her gums or teeth? 6. Ever become ill while exercising in the heat? 33. Name of student’s dentist: ______7. Had frequent muscle cramps when exercising? Last dental visit:  less than 1 year  1-2 years  greater than 2 years HEAD/NECK/SPINE: Has the student… YES NO SOCIAL/LEARNING: Has the student… YES NO 8. Had headaches with exercise? 34. Been told he/she has a learning disability, intellectual or

9. Ever had a head injury or concussion? developmental disability, cognitive delay, ADD/ADHD, etc.? 10. Ever had a hit or blow to the head that caused confusion, prolonged 35. Been bullied or experienced bullying behavior? headache, or memory problems? 36. Experienced major grief, trauma, or other significant life event? 11. Ever had numbness, tingling, or weakness in his/her arms or legs 37. Exhibited significant changes in behavior, social relationships, after being hit or falling? grades, eating or sleeping habits; withdrawn from family or friends? 12. Ever been unable to move arms or legs after being hit or falling? 38. Been worried, sad, upset, or angry much of the time? 13. Noticed or been told he/she has a curved spine or scoliosis? 39. Shown a general loss of energy, motivation, interest or enthusiasm? 14. Had any problem with his/her eyes (vision) or had a history of an 40. Had concerns about weight; been trying to gain or lose weight or eye injury? received a recommendation to gain or lose weight? 15. Been prescribed glasses or contact lenses? 41. Used (or currently uses) tobacco, alcohol, or drugs? HEART/LUNGS: Has the student... YES NO FAMILY HEALTH: YES NO 16. Ever used an inhaler or taken asthma medicine? 42. Is there a family history of the following? If so, check all that apply: 17. Ever had the doctor say he/she has a heart problem? If so, check all that apply:  Heart murmur or heart infection  Anemia/blood disorders  Inherited disease/syndrome  Asthma/lung problems  Kidney problems  High blood pressure  Kawasaki disease  High cholesterol  Other:______ Behavioral health issue  Seizure disorder  Diabetes  Sickle cell trait or disease 18. Been told by the doctor to have a heart test? (For example, ECG/EKG, echocardiogram)?  Other______19. Had a cough, wheeze, difficulty breathing, shortness of breath or 43. Is there a family history of any of the following heart-related felt lightheaded DURING or AFTER exercise? problems? If so, check all that apply:   Brugada syndrome  QT syndrome 20. Had discomfort, pain, tightness or chest pressure during exercise?  Cardiomyopathy  Marfan syndrome 21. Felt his/her heart race or skip beats during exercise?  High blood pressure  Ventricular tachycardia BONE/JOINT: Has the student... YES NO  High cholesterol  Other______ 22. Had a broken or fractured bone, stress fracture, or dislocated joint? 44. Has any family member had unexplained fainting, unexplained

23. Had an injury to a muscle, ligament, or tendon? seizures, or experienced a near drowning? 24. Had an injury that required a brace, cast, crutches, or orthotics? 45. Has any family member / relative died of heart problems before age 50 or had an unexpected / unexplained sudden death before age 25. Needed an x-ray, MRI, CT scan, injection, or physical therapy following an injury? 50 (includes drowning, unexplained car accidents, sudden infant death syndrome)? 26. Had joints that become painful, swollen, feel warm, or look red? QUESTIONS OR CONCERNS YES NO SKIN: Has the student… YES NO 46. Are there any questions or concerns that the student, parent or 27. Had any rashes, pressure sores, or other skin problems? guardian would like to discuss with the health care provider? (If 28. Ever had herpes or a MRSA skin infection? yes, write them on page 4 of this form.)

I hereby certify that to the best of my knowledge all of the information is true and complete. I give my consent for an exchange of health information between the school nurse and health care providers.

Signature of parent / guardian / emancipated student______Date______Adapted in part from the Pre-participation Physical Evaluation History Form; ©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Page 2 of 4: PHYSICAL EXAM STUDENT NAME:

STUDENT’S HEALTH HISTORY (page 1 of this form) REVIEWED PRIOR TO PERFOMING EXAMINATION: Yes  No 

CHECK ONE

Physical exam for grade:

*ABNORMAL FINDINGS / RECOMMENDATIONS / REFERRALS K/1  6  11  Other

ABNORMAL

* NORMAL DEFER

Height: ( ) inches

Weight: ( ) pounds

BMI: ( )

BMI-for-Age Percentile: ( ) %

Pulse: ( )

Blood Pressure: ( / )

Hair/Scalp

Skin

Eyes/Vision Corrected 

Ears/Hearing

Nose and Throat

Teeth and Gingiva

Lymph Glands

Heart

Lungs

Abdomen

Genitourinary

Neuromuscular System

Extremities

Spine (Scoliosis)

Other

TUBERCULIN TEST DATE APPLIED DATE READ RESULT/FOLLOW-UP

MEDICAL CONDITIONS OR CHRONIC DISEASES WHICH REQUIRE MEDICATION, RESTRICTION OF ACTIVITY, OR WHICH MAY AFFECT EDUCATION

(Additional space on page 4)

Parent/guardian present during exam: Yes  No 

Physical exam performed at: Personal Health Care Provider’s Office  School  Date of exam______20______

Print name of examiner ______

Print examiner’s office address______Phone______

Signature of examiner______MD DO PAC CRNP  Page 3 of 4: IMMUNIZATION HISTORY STUDENT NAME:

HEALTH CARE PROVIDERS: Please photocopy immunization history from student’s record – OR – insert information below.

IMMUNIZATION EXEMPTION(S): Medical Date Issued:______Reason: ______Date Rescinded:______Medical Date Issued:______Reason: ______Date Rescinded:______Medical Date Issued:______Reason: ______Date Rescinded:______

NOTE: The parent/guardian must provide a written request to the school for a religious or philosophical exemption.

VACCINE DOCUMENT: (1) Type of vaccine; (2) Date (month/day/year) for each immunization

1 2 3 4 5 Diphtheria/Tetanus/Pertussis (child) Type: DTaP, DTP or DT Diphtheria/Tetanus/Pertussis 1 2 3 4 5 (adolescent/adult) Type: Tdap or Td 1 2 3 4 5 Polio Type: OPV or IPV 1 2 3 4 5 Hepatitis B (HepB)

1 2 3 4 5 Measles/Mumps/Rubella (MMR)

Mumps disease diagnosed by physician Date:______

1 2 3 4 5 Varicella: Vaccine Disease

1 2 3 4 5 Serology: (Identify Antigen/Date/POS or NEG) i.e. Hep B, Measles, Rubella, Varicella 1 2 3 4 5 Meningococcal Conjugate Vaccine (MCV4)

1 2 3 4 5 Human Papilloma Virus (HPV) Type: HPV2 or HPV4 1 2 3 4 5

Influenza 6 7 8 9 10 Type: TIV (injected) LAIV (nasal) 11 12 13 14 15

1 2 3 4 5 Haemophilus Influenzae Type b (Hib)

1 2 3 4 5 Pneumococcal Conjugate Vaccine (PCV) Type: 7 or 13 1 2 3 4 5 Hepatitis A (HepA)

1 2 3 4 5 Rotavirus

Other Vaccines: (Type and Date)

Page 4 of 4: ADDITIONAL COMMENTS (PARENT / GUARDIAN / STUDENT / HEALTH CARE PROVIDER) STUDENT NAME: