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Imagine Bella Academy of Excellence 19114 Bella Drive Cleveland, Ohio 44119 (216) 481-1500 (Main) (216) 481-4515 (Fax) www.imaginebellaacademy.org ENROLLMENT PACKET (2017-2018)

Thank you for choosing Imagine Bella Academy of Excellence. Please complete this application as soon as possible to ensure a seat for your child.

Sincerely, Arun Dutt Principal

Student: ______

Current Grade: _____ School District______

Application Date: ______Start Date ______

Information Required: It is very important that your application be completed in full. To enroll your child in the Bella Academy of Excellence we need to have the following information:

Social Security Card Physicians Record (signed) Birth Certificate Medication Request (signed) (If Applicable) Proof of Residence CPS4 – Withdrawal to Community School (signed) Immunizations Last Report Card (not applicable for students enrolling in Kindergarten for the first time) Enrollment Application School Policies Student Medical History/Immunizations Pick up List Permanent Record Request School Policy Consent

Reminder and Comments: ______

*****Email and Scan to EMIS Coordinator*****

Printed 3/16/17 Imagine Bella Academy of Excellence 19114 Bella Drive ENROLLMENT APPLICATION Cleveland, Ohio 44119 (216) 481-1500 (Main) 2017-2018 School Year (216) 481-4515 (Fax) www.imaginebellaacademy.org MISSION: Preparing students for academic excellence and lifetime achievement.

VISION: Creating an innovative and academically excellent learning environment which is centered on students, directed by teachers, and supported by home and community

UNIFORM POLICY The Bella Academy of Excellence dress code attire consists of:  Navy Blue, Black or Khaki pants, skirts, jumpers or shorts (not more than one inch above the knee).  Any solid colored, button, or collared shirts. Shirts should be polo or oxford style. No logos, stripes, writing or pictures.  Solid Navy Blue, white, or black sweater, sweater vests and cardigans. No Sweatshirts or Hoodies. No argyle sweater vests.  Black or brown dress shoes or majority black or brown tennis shoes with black or brown laces are expected daily. No colors, glitter, designs, flashing lights, etc.  Boots ARE NOT to be worn during the school day. In case of snow boots, please provide your child with appropriate school shoes.  Navy blue, Khaki, black, or white socks.  No distracting hair accessories.  Jewelry is limited to small earrings and necklaces for both girls and boys.

VISITOR POLICY: Visitors are welcome at all times. For the safety of our students and staff, visitors must first report to the office and receive a visitor’s badge by presenting their valid Driver’s License. When visiting the school with the intent to speak with a teacher or checking in on your child, please make an appointment so that the teacher can set aside proper time to focus on your conversation. People who are regularly in the building for volunteer purposes must be fingerprinted as mandated by law.

STUDENT PICK-UP: You must sign students out when picking them up prior to dismissal. You must check in at the office upon arrival and be at least 18 years old and may be asked for identification. We do not release students between 3:30 p.m. and 4:00 p.m., unless written or verbal notice has been submitted. If this pick up time becomes habitual, Administration has the right to request documentation for early dismissal. We will send for the student to be dismissed, parents/guardians are not permitted to get students from the classroom.

STUDENT LATE ARRIVAL: Students arriving to school tardy, after 8:30 a.m., must receive a tardy slip from the front office. Parents/Guardians will not be permitted to walk the student to class after 8:30 a.m., due to instruction. Late students will not receive breakfast (service ends at 8:20 a.m.)

NONDISCRIMINATION POLICY: Our School admits students of any race, color, national and ethnic origin and does not discriminate on the basis of race, color, national origin, disability, age or sex in administration of its educational policies, admissions policies, scholarship and loan programs and athletic and other school administered programs.

Bella Academy of Excellence established under Chapter 3314 of the Revised Code. The school is a public school and students enrolled in and attending the school are required to take achievement tests and other examinations prescribed by law. In addition, there may be other requirements for students at the school that are prescribed by law. Students who have been excused from the compulsory attendance law for the purpose of home education as defined by the Administrative Code shall no longer be excused for that purpose upon their enrollment in a community school. For more information about this matter, contact a school administrator of the Ohio Department of Education.

Printed 3/16/17 Imagine Bella Academy of Excellence 19114 Bella Drive ENROLLMENT APPLICATION Cleveland, Ohio 44119 (216) 481-1500 (Main) 2017-2018 School Year (216) 481-4515 (Fax) www.imaginebellaacademy.org STUDENT INFORMATION STUDENT DATA Grade to be enrolled: ______

Last Name: ______First Name: ______Middle: ______

Birth Date: ______Birth City: ______Social Security No.: ______-______-______

Gender (Circle): M F Proof of Age (Circle): Birth Certificate Other (Please Name): ______

Ethnicity (Circle): American Indian/Alaskan Native Asian/Pacific Islander Black (non-Hispanic) Hispanic Multiracial Caucasian/White Other______

Student Address: ______

City: ______State: OH Zip: ______Home Phone: ( )______

Dwelling Type (Circle): House Apartment Other (Please Name): ______

ADDRESS:

Proof of Address (Circle or Specify in “Other”): Landlord Statement Lease Utility Bill Other:______

Is the Student address the same as the address above? Yes No If no, please fill in student’s mailing address below:

Student Mailing Address: ______

SCHOOL DISTRICT:

Has your child ever attended a Public School? Yes No

What is your Resident School District? ______(The school district where you live.)

INDIVIDUAL EDUCATION PLAN:

Does your child have an Individual Education Plan (IEP)? (Please circle.) Yes No

Has your child ever had an Individual Education Plan (IEP)? (Please circle.) Yes No __ KINDERGARTEN:

Did your child attend Kindergarten? (Please circle.) Full Day Half Day Not At All

Did your child attend Preschool? (Please circle.) Full Day Half Day Not At All _

As a Community School, parent involvement is a very important. By enrolling your child, you are agreeing to play a vital role in your child’s education. You are required to drop off and pick up your child on time, attend conferences, return forms in a timely manner and call in student absences. More importantly, we will count on you to volunteer and participate regularly in the best interest of the school.

I support the educational philosophy of Imagine Schools and hereby submit my application to enroll my child.

______Parent/Guardian Signature Parent/Guardian Printed Name Date

Printed 3/16/17 Imagine Bella Academy of Excellence 19114 Bella Drive ENROLLMENT APPLICATION Cleveland, Ohio 44119 (216) 481-1500 (Main) 2017-2018 School Year (216) 481-4515 (Fax) www.imaginebellaacademy.org ADDITIONAL ASSISTANCE FORM

Student Name ______Student Date of Birth ______(Please Print) Name of School Your Child Attended Last Year: ______1. Has your child ever repeated a grade? Yes No 2. If yes, then what grade was repeated? ______3. Was your child’s attendance good at their previous school(s)? Yes No 4. Did your child experience any difficulties at their previous school? Yes No If yes, please explain: ______5. Did you child receive any extra help at his/her previous school? Yes No (For example: Title One, counseling, before or after school tutoring, etc.) If yes, please explain: ______6. Is your child performing at grade level in reading and math? Yes No Please explain ______7. Was your child tested due to academic or behavior issues at his/her previous school? Yes No If yes, please explain: ______8. Has your child been identified as having a disability either by an outside source or his/her previous school? Yes No If yes, please explain: ______9. Does your child currently receive special education services for speech or another disability? Yes No If yes, please explain: ______10. If you answered “Yes” to #4 then, do you have a current, signed copy of your child’s Evaluation Team Report (ETR) and Individualized Education Plan (IEP)? Yes No If you answered yes then you will need to bring the ETR and/or IEP with you when you return this form if your child did not attend Bella Academy of Excellence last year. Home Language Survey 1. What language did your child speak when they first learned to talk? ______2. What language does your child use most frequently at home? ______3. What language do you use most frequently to your child? ______4. What language do the adults at home most often speak? ______5. How long has your child attended school in the United States? ______

For School District Personnel: Printed 3/16/17 If the answer to any of the first four questions in Home Language Survey is a language other than English, indicate the student’s native/home language in EMIS Student Data Element (GI270), and proceed to assess the student’s English language proficiency. Imagine Bella Academy of Excellence 19114 Bella Drive ENROLLMENT APPLICATION Cleveland, Ohio 44119 (216) 481-1500 (Main) 2017-2018 School Year (216) 481-4515 (Fax) www.imaginebellaacademy.org STUDENT MEDICAL RECORDS STUDENT DATA:

Last Name: ______First Name: ______MI: _____

Gender (circle): M F Birth Date: ______

HEALTH HISTORY: CIRCLE ANY CONDITIONS THAT HAVE BEEN EXPERIENCED BY YOUR CHILD:

Chicken Pox Diabetes Eye Problems/Vision Frequent Ear Infections

Tubes in Child’s Ears Frequent Frequent Nosebleeds Frequent Sore Throat Headaches Infections

High Fevers Poor Hearing Seizures or Epilepsy Sickle Cell Disease

Is your child sick a lot? Yes No If Yes, please explain:______

MAJOR ILLNESSES, INJURIES OR SURGERIES: Has your child had any major illnesses, injuries or surgeries? Yes No If Yes, please list:

1. ______2. ______3. ______4. ______

MEDICATIONS: Does your child take any medications frequently or daily? Yes No If Yes, what medications are taken daily? ______If Yes, what medications are taken frequently, but not daily? ______This child is usually (circle one): very active normally active rather inactive

ALLERGIES: Has your child been diagnosed with asthma or allergies by a doctor? Yes No If Yes, please explain: ______

Is your child on any medicine (prescription or over-the-counter) for allergies? Yes No If Yes, please explain: ______

Please list and describe allergies or reactions to: Medicines/drugs: ______Foods/Plants/Others: ______Bee/Wasp Stings: ______

Printed 3/16/17 Imagine Bella Academy of Excellence 19114 Bella Drive ENROLLMENT APPLICATION Cleveland, Ohio 44119 (216) 481-1500 (Main) 2017-2018 School Year (216) 481-4515 (Fax) www.imaginebellaacademy.org STUDENT EMERGENCY CONTACT/PICK UP LIST CUSTODY INFORMATION: STUDENT NAME: ______

Who has custody of this student NOW? (Circle Only One:) Both Parents Mother Only Father Only Guardian Other I certify that I have legal custody of ______. Signature ______Date______. Custodial parents may always pick up their children. However, in an event that others may need to pick up your children, please list people that are allowed to pick up your children. These people will be required to show their driver’s license for identification so please include information below that will match this information. If one of these people will be picking up your child, please call the school office in advance to notify us of the change. PARENT/GUARDIAN INFORMATION (PLEASE PRINT): PARENT/GUARDIAN 1 PARENT/GUARDIAN 2 Last Name: Last Name: First Name: First Name: Address: Address: City : City: State: Zip: State: Zip: Relationship to Student: Relationship to Student: Employment: Employment: Work Phone: Work Phone: Home Phone: Home Phone: Unlisted? Yes No Unlisted? Yes No Cell Phone: Cell Phone: Fax Number: Fax Number: Email: Email:

EMERGENCY CONTACT INFORMATION and PICK UP CONTACT (PLEASE PRINT): FIRST PERSON TO CONTACT SECOND PERSON TO CONTACT Last Name: Last Name: First Name: First Name: Address: Address: City: ______State: ___ Zip: ______City: ______State: ____ Zip: ______Relationship to Student: ______Relationship to Student: ______Employment: ______Employment: ______Work Phone: ______Ext: ______Work Phone: ______Ext: ______Home Phone: ______Unlisted? Yes No Home Phone: ______Unlisted? Yes No Cell Phone:______Cell Phone: ______E-Mail Address: ______E-Mail Address: ______

**If additional contacts need to be added, please ask for another form** Printed 3/16/17 Imagine Bella Academy of Excellence 19114 Bella Drive ENROLLMENT APPLICATION Cleveland, Ohio 44119 (216) 481-1500 (Main) 2017-2018 School Year (216) 481-4515 (Fax) www.imaginebellaacademy.org REQUEST FOR PERMANENT RECORDS

______has enrolled in Imagine Bella Academy of Excellence and the

student’s first day was ______.

Please send the following information to:

Imagine Bella Academy of Excellence Enrollment Office 19114 Bella Drive Cleveland, Ohio 44119

PLEASE SEND ANY AND ALL INFORMATION BELOW: __ Social Security Card __ Grade Card (or information about pupil placement) __ Birth Certificate __ Attendance __ Proof of Residency __ Intervention Assistance Team Documents __ Immunization Record __ Special Education IEP/MFE __ All Medical Records __ Expulsion/Suspension Documents __ Custody/Court Documents __ Retention Records (from any school year) __ Copy of Student’s Data Form __ Third Grade Reading Guarantee Test __ Cumulative Records Scores/Status/Fall Reading Diagnostics (K-3)

TO BE COMPLETED BY PARENT OR GUARDIAN:

Name of school your child last attended: ______

School Address:______

City: ______State: OH Zip: ______

Phone: ______Fax: ______

Last Grade Attended: ______Date of Birth______

Other Schools Attended Previously: ______AUTHORIZATION:

PRINT NAME of Parent/Guardian: ______

SIGNATURE of Parent/Guardian: ______

Date: ______SCHOOL POLICY AUTHORIZATIONS

Printed 3/16/17 Imagine Bella Academy of Excellence 19114 Bella Drive ENROLLMENT APPLICATION Cleveland, Ohio 44119 (216) 481-1500 (Main) 2017-2018 School Year (216) 481-4515 (Fax) www.imaginebellaacademy.org

AUTHORIZATION – DRESS CODE, VISITOR’S & LATE ARRIVAL POLICY

My signature below indicates that I have read the DRESS CODE POLICY, the VISITOR’S POLICY and the LATE ARRIVAL POLICY. I understand the consequences that are associated with not complying to the said policies, and I agree to the terms stated within said policies.

PRINT NAME of Parent/Guardian:

______

SIGNATURE of Parent/Guardian: Date:

______

MEDIA INTERVIEWS & PHOTO RELEASE

From time to time outside agencies (local radio or television stations, newspaper or community/state agencies) highlight exemplary programs in our area. This often involves video taping or taking pictures of students in the classroom setting and/or asking students for their opinions or questions about their educational experiences.

While reading that the public has a right and a responsibility for access to information about the activities in our schools; Bella Academy of Excellence is very selective in granting such access to the classroom. Please indicate your feeling regarding your child’s involvement in media events by signing one of the following statements:

AUTHORIZATION – MEDIA INTERVIEWS & PHOTO RELEASE

I, the parent/guardian of ______DO give my permission for my child to participate in approved media interviews/video tapes/photographs and release the school and said agency from all claims based upon this activity.

SIGNATURE: ______Date: ______

______

I, the parent/guardian of ______DO NOT give my permission for my child to participate in approved media interviews/video tapes/photographs.

SIGNATURE: ______Date: ______

STUDENT MEDICAL RECORDS PHYSICIAN RECORD Printed 3/16/17 Imagine Bella Academy of Excellence 19114 Bella Drive ENROLLMENT APPLICATION Cleveland, Ohio 44119 (216) 481-1500 (Main) 2017-2018 School Year (216) 481-4515 (Fax) www.imaginebellaacademy.org

STUDENT NAME: ______

SCREENINGS (can be completed by nurse or physician):

Height: _____ ( %) Weight: _____ ( %) Blood Pressure: _____ ( %)

VISION HEARING SPEECH & LANGUAGE

Distance Acuity R_____ L_____ Audiometric Thresholds: Speech Assessment:

Muscle Balance: Pass Fail Not Done Right Ear: Pass Fail Not Done Done Not Done

Farsightedness: Pass Fail Not Done Left Ear: Pass Fail Not Done Child has possible problem with:

Color: Pass Fail Not Done Other Tests (specify): ______Articulation Yes No Rhythm Yes No Child wears glasses? Yes No Child wears hearing aid? Yes No Voice Yes No Language Yes No Tested with glasses? Yes No Tested with hearing aid? Yes No Speech evaluation recommended? Referral made? Yes No Referral made? Yes No Yes No

IMMUNIZATIONS (can be completed by nurse or physician):

DPT 1st ______2nd ______3rd ______4th ______

Polio 1st ______2nd ______3rd ______4th ______

Hep B 1st ______2nd ______3rd ______

Mumps 1st ______2nd ______Tuberculin Test Date: ______

German Measles (Rubella) 1st ______2nd ______Results: Negative___ Positive___

Measles (Rubeola) 1st ______2nd ______

Varicella 1st ______2nd______

EXAMINATIONS (can be completed by nurse or physician):

Head ______Mouth______Genitalia______Lungs______

Neck______Teeth______General Condition______Hernia______

Nose______Abdomen______Orthopedic______Urinalysis______

Throat______Heart______Nervous System______

PHYSICIAN REMARKS & RECOMMENDATIONS:

Physician Remarks & Recommendations: This child is authorized to participate fully in:

- classroom & academic activities Yes No - physical education classes Yes No - competitive athletics Yes No - contact & collision sports Yes No Physician Signature: ______

Date: ______(Specify Limitations in REMARKS) STUDENT MEDICAL RECORDS MEDICATION REQUEST

Printed 3/16/17 Imagine Bella Academy of Excellence 19114 Bella Drive ENROLLMENT APPLICATION Cleveland, Ohio 44119 (216) 481-1500 (Main) 2017-2018 School Year (216) 481-4515 (Fax) www.imaginebellaacademy.org

The following student is under my care and should receive the medication indicated below. It is not possible to arrange for medication to be taken at home under the supervision of a parent, and therefore, must be taken during school hours.

ONE MEDICATION PER CARD

Last Name: ______First Name: ______MI: ___ Birth Date: ______

Student Address: ______

City: ______State: OH Zip: _____ Home Phone: ______

Name of prescribed medication:______Dosage: ______

Number of times/intervals medication is to be administered: ______

Dates administration to begin and end: ______

Adverse or severe reaction that should be reported to physician: ______

Special instructions for administration of medication: ______

The medication can be safely administered by non-medical personnel: Yes No

______Physician’s Name Phone Number

______Physician’s Signature Date

Printed 3/16/17