OPEN-ENROLLMENT CHARTER CONTRACT RENEWAL APPLICAnON
Sectio" I. Cllrrellt (nformation in Charter School Trucking System
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2 Section II. Contact Information
The persons listed below will be contacted by agency staff if there are issues to be resolved in any of the sections.
Superintendent Contact Information:
Superintendent's Name: I~~ner ,~~rj~,
Telephone Number: /(713)343-33331205
Fax Number: 1
E·m.iI Address: ISttt_ri~~harmonYtx.org
Charter Holder Board Chair Contact Information:
Charter Holder Board Chair's Name: Telephone Number: I~:;,:;:--- Fax Number: 1(713) 777-8555
E-mail Address:
Application Preparer's Contact Information:
Contact Name: l~at~hAY~ ...... Telephone Number: 1(972) 234-9993
Fax Number: k972)234:999~.
E-mail Address: IraY@harmOnYlx,org ..
Chat·ter School Website:
Web address:
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Chapter 12 ofthe Texas Education Code (TEC), specifically §12.1 04(b)(2)(L), makes explicit that open-enrollment charters are required to comply with TEC Chapter 39, Subchapter D, Financial Accountability. TEC §39.084, titled Posting ofAdopted Budget, states the following:
(a) On final approval ofthe budget by the board oftrustees, the school district shall post on the district's Internet website a copy ofthe budget adopted by the board of trustees. The district's Internet website must prominently display the electronic link to the adopted budget.
(b) The district shall maintain the adopted budget on the district's Internet website until the third anniversary ofthe date the budget was adopted.
Provide the web address ofthe adopted budgets:
http://www.hsawaco,orgflmidframe=/Announcements/index,asp
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4 Section IV. Organizational Charts
Submit, as Attachment I, the organizational chart for the charter school that specifies the administrative positions including the title and name ofthe individual currently in each position. See Attachment 1- Organizational Chart for Charter School District Submit, as Attachment 2, a chart that identifies all other entities under the direction ofthe charter holder. This would include entities and/or programs that the charter holder governs/manages in addition to the charter school. See Attachment 2-0rganizational Chart of Charter Holder-Cosmos Foundation Inc.
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5 Section V. Admission Policy
A. Specify the period during which applications for admission are accepted. TEC. § 12.117, requires that a charter school establish a reasonable application deadline/or the submission ofapplications/or admission.
Beginning of Period End of Period (Month/Duy) (MontblDuy)
lJAN.IO /MARCH 15
B. Ifthe school admits students by lottery when the number of admissions applications received exceeds the number of available spaces, describe the procedures followed in conducting the lottery. Type Below: A lottery is to be conducted ifthe number ofapplicants exceeds the maximum enrollment. Each student will be assigned a number. Numbers will be written on a piece ofnpaper (1" by 2") and folded twice. Numbers will be placed in a conlaincrand randomly drawn one number at a time by the principal or hislher designee. The lottery will be supervised by at lenst one member ofthe sponsoring entity or his! her designee and by arepresentative from the Cosmos Foundation Central office. -< rn ~ C"l C. Ifthe school utilizes a lottery when oversubscribed, are any calegories ofapplicants exempted from the 10fl8i.y? ::r en :l> Check One: (0 Yes rn > ;g ::0::0 = rn-; = I c:>rn r* ~ VI -< - m=en <= r Not applicable (because lotteries are not utilized) :i! IT1_ Cl~= If"Yes" was indicated in C above, state the categories ofapplicants that are exempted. N r-= Type Below: OO en
Children ofthe school's founders and teachers (so long as the total number ofstudents allowed constitutes only asmall percentage of the total enrollment) as pennitted by the federal guidance on the Charter Schools Program are exempt from lottery requirements.
D. lfthe school utilizes a lottery when oversubscribed. specifY the approximate date on which a lottery will be conducted.
Approximate Date ofLottery (MontblDay)
/MARCH25
E. lfthe school does not utilize a lottery when oversubscribed, but rather tills the available positions in the order in which applications were received before the expiration ofthe application deadline (i.e., a "first-come, first-served" admission process), describe the manner in which the school notifies the community ofthe opportunity to apply for admission. TEe. §12.117. requires a charter schoollhaluses afirsl-come, first-served admission process when oversubscribed to publish a notice in a newspaper ofgeneral circulation not later than the seventh day before the application deadline. Type Below:
N/A
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6 F. Ifthe school has a separate process for re-enrollmen~ state the process and the timeline to be used. Type Below:
Returning students (students who currently attended the school and intend to return the next school year) arc given priority in admission, if they notifY the school oflheir intent to return for the next school year by February 1st of the each school year.
O. State the procedures for processing applications received once the application deadline has passed. Type Below:
Ifa student applies to the school outside ofthe designated application period, the student will be placed on a waiting list in the order of the date in which the application is received.
H. Describe the infonnation that an applicant must provide in order to be considered far admission. Applicants may not be required 10 provide copies oftranscripts or a/her academic records unlif afier they are offered admission and are enrolling. Furthermore, a sludent may nol be precludedfrom enrolling due 10 Ihe charIer school's failure to receive information requiredfar enrallmentfram the student~ parent or guardian or previous school. See TEC. §25.002. Type Below:
The application fonn must include the following items; Applicant's name. birth date, current school name, current grade level, residential address, phone numbers, parents' name, contact inronnation, and signature. The application fonn must also include infonnation regarding the applicant has a sibling already admitted to attending the school and whether the applicant has a documented history of a criminal offense. Applicants are not be required to provide transcript or other academic records until after they are oITered admission.
r. The charter holder certifies that the non-discrimination statement required by TEC, §12.1 I I (a)(6) is printed in the school's admission policy. TEC, §I2.111 (6) requires that a charter school's admission policy include a statement that the school will not discriminate in admissions based on gender, nalionalorigin, ethnicily. religion. disability, academic, arlis/ic, or athletic ability. or the district the child would athenvise aI/end. Check One: .. Yes
rNa
J. Does the admission policy either require or pennit the school to exclude from admission all students with documented histories ofa criminal offense, ajuvenile court adjudication, or discipline problems underTEC Chapter 37, Subchapter A as authorized by TEe, § 12.1 II(a)(6)? Check One: .. Yes (The school excludes such students or reserves the right to exclude such students from admissions.)
r No (The school does not deny admission to such students based on their documented histories of misconduct.) Submit as Attachment 3, a cUfTent copy ofthe admission poticy that incorporates the information provided in the above answers to questions A through H and any other relevant information; as Attachment 4, a blank copy of the current admission application (i.e., the information requested when the student first seeks admission); and as Attachment 5, a blank copy of the current enrollment formes) (i.e., the information required once an applicant has been offered admission and is registering for enrollment)
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7 Section VI. Special Education Assurances
The charter holder certifies that it has policies and procedures in place that ensure implementation of all federal laws and regulations, Texas laws, State Board of Education (SBOE) and commissioner of education rules related to students with disabilities and further certifies that any future amendments to the laws, regulations, and rules will be incorporated and implemented.
------~_l_J_21__-1Q-.l[------s;;;;;,;;;,-;c1~"~;;;'-Ch";---- Date (Must sign in blue ink)
Oner U. Celepcikay -< ron >< ~ C":l Printed Name of Charter Holder Board Chair ". :r: en J> rn ;:g= :0:0 <::> en""" =co I CJrTl ".. VI rn= -< -en <0 = ~ m::r: "..= 0= en ...... C) 2: N en =-< CO
Page 12 8 Section VII. Assurances Regarding Charter Schools Serving Students at Residential Facilities
If the charter school is not currently approved to serve students at residential facilities, please indicate N/A on the signature line.
Ifoperating a charter school campus on the site ofa residential facility (RF) or serving students residing in or receiving services from an RF, the charter holder chair certifies the following:
Compliance with Special Education Requiremeltts: The charter holder assures that it will comply with all of the requirements for the provision of educational services to students with disabilities as mandated by the Individuals with Disabilities Education Act, as amended, the Texas Education Code, and federal and state special education regulations. The charter holder acknowledges that state and federal special education requirements require, among other things, that it provide a free and appropriate public education (FAPE) in the least restrictive environment (LRE) to students with disabilities residing in RFs. The charter holder further assures that it will provide, or seek the provision of, a FAPE to students with disabilities, which may require it to contract with outside service providers or another local educational agency to provide necessary services and supports to students with disabilities.
Geographic Boultdaries: The charter holder assures that it will accept students who reside in the school district(s) that are within each new campus's geographic boundaries regardless of the presence or absence ofa disability or admission to or participation in an RF program.
Admissiolts Criteria: The charter holder assures that its admissions criteria will not be based on the presence or the absence of a disability or on gender, national origin, ethnicity, religion, academic, artistic or athletic ability, or the district the child would otherwise attend.
School Cftoice: The charter holder assures that parents/legal guardians (or adult students) will be advised that they may choose to enroll their child in either the charter school or the local public school district and that the elected choice will be documented in writing and filed for purposes of review or audit by the Texas Education Agency (TEA), external auditor, Of other entity.
Residelttial Facilities Moltitoriltg (RFM) System: The charter holder assures that it understands that, pursuant to 19 Texas Administrative Code (TAC) §97.1072, there is a specific system for monitoring school districts and charter schools that serve students with disabilities who reside in RFs. The charter holder further assures that it understands that it will be required to report data related to students with disabilities residing in RFs in TEA's data collection system known as RF Tracker and that it may be subject to RFM intervention activities and on-site visits based upon a review ofthe data it reports or on random or other means of selection.
Traillillg: The charter holder assures that all personnel involved with serving students with disabilities residing in an RF and personnel involved with reporting data in RF Tracker will receive training on the RFM system.
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9 Section VII. (Continued) Assurances Regarding Charter Schools Sel'ving Students at Residential Facilities
The charter holder assures that this assurance document has been shared with, and understood by, the RF board and that the RF board has acknowledged its understanding of all federal laws and regulations, Texas laws, State Board of Education (SBOE) and commissioner of education rules related to chruter schools serving students at residential facilities and further certifies that any future amendments to the laws, regulations, and rules will be incorporated and implemented.
N/A
Signature of Charter Holder Board Chair Date (Must sign in bille ink)
PJinted Name ofChruter Holder Board Chair
Please write N/A in the signature line if the charter serves NO students with disabilities who reside in residential facilities.
-< ><""' f::::l C"") en ::r: """ > l> ""' ;g :0:::0 = ." -l c:>= I CJ'" :- VI .,,:::0 ::! -en Page 14 10 Section VIII. Bilingual/ESL, Section 504, and Dyslexia Assurances TEC, Chapter 29, Subchapter E, TEC §12.104(b)(2)(G), and 19 TAC §§89. 1201-. 1265 require charter schools to identifY limited English proficient students based on state criteria and to provide an appropriate bilingual education or English as a second language program conducted by teachers certified for such courses. A. The charter holder certifies that it has policies and procedures in place that ensure that it complies with the legal and regulatory requirements concerning identifYing and providing appropriate educational services to limited English proficient students. Check One: (0 Yes ("'No Section 504 of the Rehabilitation Act of 1973,29 Us.c. §794, prohibits discrimination on the basis ofdisability in any program receiving federal financial assistance. A recipient that operates a public education program or activity shall provide a free, appropriate public education to qualified individuals. B. The charter holder certifies that it has policies and procedures in place that ensure that it complies with the legal and regulatory requirements concerning identifYing and providing appropriate educational services to students protected by Section 504. Check One: (0 Yes ("'No TEC §38.003, TEC §12.J04(b)(2)(K), 19 TAC §74.28 and Section 504 of the Rehabilitation Act of 1973,29 Us.c. §794, require charter schools to identifY students with dyslexia or related disorders and to provide appropriate educational services. C. The charter holder certifies that it has policies and procedures in place that ensure that it complies with the legal and regulatory requirements concerning identifYing and providing appropriate educational services to students with dyslexia or related disorders. Check One: (0 Yes ("'No I further certifY that any future amendments to the laws, regulations, and rules will be incorporated and implemented. --Si;:;"-;;:;;"iCl~-'--;;"Ch;;;---- ______::;,!-L~~JL------(Must sign in bl:~~~tt) ;;5 ~ ;p en rn Oner U. Celepcikay = C?= :» -< Printed Name of Charter Holder Board Chair = Page 15 11 Section IX. Certificate of Acknowledgement This section requires at least a majority ofthe governing body of the charter holder to certify that it has had an opportunity to review the completed renewal application and has authorized, during an open meeting, submission of the application to the commissioner ofeducation for consideration of renewal of the charter, CERTIFICATE OF ACKNOWLEDGEMENT The undersigned members of the governing body of the charter holder hereby acknowledge that they have had an opportunity to review the completed renewal application and have authorized its submission, during an open meeting, to the commissioner ofeducation for consideration of the renewal of the charter: 'Members are to sign the acknowledgement during an open meeting; therelore, the date next to each signature must be the same, Typed Name Signature (Type name next to corresponding Date' signature) (Must sign in blue ink) lor. OncrU. Cclcpcikay III~ IMarCh 15,2011 IEllen MacDonald Ir:dL;tj±",,,,.e~,~_~r-a-r-Ch-15-'-2-0-1-1------ r IC-e-ng-i-ZI-la-n-K-e-s-k-in------1 ~ IMarCh 15,2011 Irl/~ IrM-a-r-ch--I'-,-c-O-I-I------ Dr. Mustafa A. Atik f./ti(J I " " I I rID-r-.B-i1a-I-A-k-.in------1 ///~ \MarCh 15,2011 I' ,------ ..------1 =0 rn ~ C") :>< ::c ""'"cn » ..,., ....."'0 ::0 ==rn-< = om =C? I :0 VI I'Tl -< -en """ Page 16 1.2. CHARTER SCHOOLS RECEIVED lOll APR -5 PH I: 28 mAS EDUCATION AGENCY ATTACHMENT - 1 Organizational Chart for the Charter School District 13 CHARTER SCHOOL DISTRICT ORGANIZATIONAL CHART Cosmos Foundation Inc. Board of Directors .. • Hannony Public Schools Central Office ! Hannony Science Academy-Waco (161-807) - ~ -- - -... Harmony Science Harmony Science Harmony Science Harmony School of Academy-Waco Academy-Garland Academy-Dallas Innovation-Dallas (161-807-001) (161-807-002) (161-807-003) (161-807-004) (Same As) Principal (Same As) (Same As) Assistant Principal Assistant Principal IDean of Discipline) (Curriculum & Instruction) 1 1 1. PEIMS Coordinator 1. Special Ed. Coordinator 2. Administrative Assistant" 2. Counselor 3. Food Se",lces SUpB",1sor' 3. BElESL Coordlnato," 4. Custodian 4. GlftedlTalented 5. School Nurse Coordinator- 6. Attendance Clerk" S, Teachers 6. Teachers AIds" ·Please Note that the chart above is designed to show administrative functions rather than individual positions. In other words, multiple tasks can be performed by the same person If need arises (I.e. a payroll coordinator can be account payable clerk and benefrt coordinator). Additional positions may be created as needed. Please also note that business manager Is not Included in this chart because business related services (including but not limited to payroll and a=unting) is done at the Cosmos Central Office. 14 CHARTER SCHOOLS RECEIVED 2011 APR -5 PH I: 28 mAS EDUCATION AGENCY ATTACHMENT - 2 Organizational Chart for All Other Entities Under The Direction of The Charter Holder 15 State Board of Education Commissioner ofEducation & TEA • Cosmos Foundation Inc. (Central Office) IHSDlsrovefY'/'looston. , I HS--,! High-HouSton I fSFlne Art&Tech.;Houstonl HSA'Ga~ancj , IHSMvancement:Houston I HSI..san AirtOflIo I - I I I HSA-Austin I HSA-Houston I I HSA-San Antonio I I==' HSA-Austln North , I HSI-Houston I I HSA-Waco I HSE-Austin , HSE-Houstim I HSA-Larado I I I I ( I HSS-Austin , HSA-Houston NW I HS.A-8eaumont I - I I I I HSA-Pallas , I I . HSS-Houstop I I HSA-8ryan I I HSWalll>S I I !is.lngenulty-Houston . I I HSA-Lubbock I HSA-Fort Worth , HSA-8rowsvllle I I I HSEOdeavor-HqiJston I I . HSA-Euless , HSA-ElPaso HSNature.Dalilis I - I I I t I HSA-Grand Prairie I I HSI-EI Paw I I HsA- OdesSa I HSA :Harmony Science Academy HSE :Harmony School of Excellence HSS :Harmony School of Science HSI :Harmony School of Innovation HS Ingenuity :Harmony School of Ingenuity HS Endeavor . :Harmony School of Endeavor HSAdvancemehf:l'larThciriy SChool cif·Advancement HSDisGove[y .~':H TEXAS EDUCATiON AGENCY ATTACHMENT - 3 Admission Policies and Procedure 17 Admission Policies and Procedures for Harmony Public Charter Schools Beginning and Ending Dates of Application Periods Harmony Schools require applicants to submit a complete application form in order to be considered for admission. For the first year of operation of a campus, application period starts on January 10th (beginning date) and ends on June 25th (closing date). For the following years, the beginning and ending dates of the application period shall be January 10th and March 15th of each year, respectively. Lottery Procedures and Date when a grade or class is oversubscribed A lottery is to be conducted if the number of applicants exceeds the maximum enrollment. The lottery shall take place within fifteen days after the closing date of the application period. Each stUdent will be assigned a number. Numbers will be written on a piece of a paper (1" by 2") and folded twice. Numbers will be placed in a container and randomly drawn one number at a time by the principal or his/her designee. The lottery will be supervised by at least one member of the sponsoring entity or his/her designee and by a representative from the Cosmos Foundation Central office. Results of the lottery shall be certified by a notary public. Development of a Waiting List The lottery will be paused momentarily once number of stUdent names reach proposed enrollment cap. Then the drawing will continue and a waiting list will be developed by pulling the remaining names until all names are pulled. As space become available, applicants will be called from the waiting list with the lowest number assignment. Admission Process of Returning Students Returning students (students who currently attended the school and intend to return the next school year) are given priority in admission, if they notify the school of their intent to return for the next school year by February 1,t of the each school year. . Siblings Policy and Children of the School's Founders and Teachers Siblings of returning students will not be exempt from the lottery and will not obtain automatic admission. Siblings of returning students are required to follow regular admission procedures. However, children of the school's founders and teachers (so long as the total number of students allowed constitutes only a small percentage of the total enrollment) as permitted by the federal guidance on the Charter Schools Program are exempt from lottery requirements. 18 Applications that are submitted outside of the designated application period If a student applies to the school outside of the designated application period, the student will be placed on a waiting list in the order of the date in which the application is received. Students With documented histories of a criminal offense and/or misconduct Students who have a documented history of a criminal offense, juvenile court adjudication, listed in TEC, §12.111 (6), or other serious discipline problems listed under TEC, Chapter 37, Subchapter A will be excluded from enrollment as TEC, §12.111 (6) authorizes a charter school to do so. Documents and Information Applicants are Required to Provide Applicants must sUbmit a completed application form in order to be considered for admission. The application form must be signed and dated by the parent(s). The application form must include the following items: D Applicant's name (first, last, and middle names) D Applicant's birth date D Applicant's current grade level and grade applied for D Applicant's residential address D Phone numbers D Applicant's current school and district names o Applicant's parents' name and signature D Whether the applicant has a sibling already admitted to attending the school D Whether the applicant has a documented history of a criminal offense, a juvenile court adjudication, or discipline problems under Chapter 37 of the Education Code. Applicants are not required to provide transcript or other academic records until after they are offered admission. Reporting Transfer Students Pursuant to Civil Action 5281 Civil Action 5281 requires that TEA not approve student transfers where the effect of such transfers changes the majority or minority percentage of the school population by more than one percent in either the sending or receiving district Harmony Schools comply with reporting transfer students pursuant to Civil Action 5281 by using the student transfer system provided on the Texas Education Agency website under PEIMS section. Non-discrimination Statement as Part of the School'S Admission Policy It is the policy of Harmony Schools to comply with all state and federal regulations regarding admission and not to discriminate during the admission and the lottery process on the basis of gender, national origin, ethnicity, religion, disability, academic, artistic, athletic ability, or the district the child would otherwise attend. 19 CHARTER SCHOOLS RECEIVED 2Il11 APR -5 PH I: 30 TEXAS EDUCATION AGENCY ATTACHMENT - 4 Application Form 20 CAMPUS NAME campus Address, Phone, ancl Fax Numbers APPLICATION FORM DEAR PAR£NT(S} AND APPUCANT: Thankyou for your interest in our school. Please, fill out this application form completely. Falsifications, misrepresentations, or omissions may disqualify your application. Information you supply may not be given to any other companies. Applications received unsigned or Incomplete may not be considered for acceptance. Does the applicant have a sibling who's attending this school or other Harmony campuses?ClYes ClNo Does the student have any documented history of a criminal offense or juvenile court adjudication? ClYes ClNo Ifyes, please explain:: ______ We/I, the undersigned, hereby certify tha~ to the best ofour/myImowledge and belief, the answers tn the foregoing questions and statements made by us/me in this application are complete and accurate. Well understand that any false infonnation, omissions, or misrepresentations of facts may result in rejection of this or future dismissal Please mall or fax the completed application to: SCHOOL NAME Street Address • Tel: 123-456-7890. Fax: 123-456-7890 E-mail: jnfo@harmooytJ< prr + URL: www.bannooytx.ore NON-DISCRIMINATION STATEMENT: rt Is the policy of Harmmy SChools to comply with all state and fEderal regulations regarding admission and not to dlsairrinate during the admission and the lotte!y process on the basis of gender, national origin, ethnfdtyl religion, disability, academic, artlstlc, athletic ability, or the district the chDd would otherwise attend. 21 CHARTER SCHOOLS RECEIVED ZIlIi APR - 5 PM 1:)0 iEXAS EDUGAnON AGENCY ATTACHMENT - 5 Enrollment Forms 22 HARMONY PUBUC SCHOOLS ENROLLMENT FORM ASIAN BLACK or AFRICAN AMERICAN NATIVE HAWAllAN I PASlFlC ISLANDER Last Revised: Apnl 2010 Page10f 2 23 I UNDERSTAND THAT THE PHOTOS AND THE NAMES MAY BE USED FOR DISPLAY, PUBUCATION, VlD,O, WEBSITES, OR BY OTHER o o MEDIA, SUCH AS LDCAl NEWSPAPERS AND/OR TElEVISJON STATION5.1 ALSO AGREE THAT THIS PERMISSION WIll HAVE NO TIME UMlTATIONS. I ALLOW MY CHIUD TO PARTIOPATE IN ALL ATHlETIC EVENTS AT HARMONY SCHOOLS, WITH THE UNDERSTANDING THAT THE o o PARENT/GUARDIAN IS RESPONSIBLE FOR ANY MEDICAl COSTS INCURRED IN THE EVENT OF AN INJURY. IjWE, THE UNDERSIGNED, HEREBY CERTIFY THAT, TO THE BEST OF MY/OUR KNOWLEDGE AND BEUEF, THE ANSWERS TO THE FOREGOING QUESTIONS AND STATEMENTS MADE BY ME/US IN THIS APPUCATION ARE COMPlETE AND ACCURATE. IjWE UNDERSTAND THAT ANY FALSE INFORMATION, OMISSIONS, OR MISREPRESENTATIONS OF FACTS MAY RESULT IN REJECTION OF THIS APPUCATION OR FUTURE DISMISSAL OF THE APPUCANT.I AND MY CHIUD AGREE TO FOLLOW THE RUlES OF HARMONY SCHOOLS AS STATED IN THE STUDENT HANDBOOK. ~ FAlSlFYING INFORMATION ON THIS FORM IS A VIOLATION OF THE LAW. VIOLATION MAY RESULT IN PROSECUTION (SECTION 37.10 OF THE TEXAS PENAL CODE). Signature of Male Parent Date Signed (mmldd/yyyrl IX Driver's Ucense No Date of Birth lAs ~LiJred byTEC US'oo2(Fl) SIgnature of Female Parent Date Signed (mmtddfmyl IX Driver's Ucense No Date of Birth [As R~lmd by nc 12S.002{F}1 Signature of legaJ Guardian Date Signed /mm/dd/;'W)'l IX Driver's Ucense No Date of Birth fA.I Required by TEC !izs.cm(f)) last Revised: Apnl 2010 Page 2 of 224 HARMONY PUBLIC SCHOOLS EMERGENCY INFORMATION FORM Student's Name: __-;-:=______=:-;-______---,=;:,;:: Last First Middle Grade: Date of Birth: ______ Address:_~==~----~------~~------~~~-~~- Street City . State Zip Parent/Guardian: Name: ______Relationship:___Phoneltil ______iJilQ ______JQl _____ Name: ______Relationship:___ Phoneu(.aHL)_____.l("'Wl"-_____""(OLt)_____ Physician: ______Phone:______,lnsurance:.______ List anyone authorized to pick up your child in case of illness or injury and you cannot be reached at the above numbers. Only those persons listed will be allowed to pick up your child without additional approval from you. Name:______Relationship:___,Phone''''IH:lj)'-____-'-'!(Wl1L_____""IO"')_____ Name:______,Relationship..·____Phone''''(H:lj)'-_____(i.!!W)1L_____''''(O''')_____ AUTHORIZATION TO ADMINISTER NON·PRESCRIPTION MEDICATION I hereby authorize the school nurse or persons designated to administer medication to administer the following non·prescription items as needed by my child. (Please Initial in blanks for authorized medications.) __Acetaminophen (Tylenol) __Benadryl ___Sudafed __Ibuprofen ___Antacid Topical and/or first aid items may be utilized by school personnel unless there is a specific objection by the parent/guardian. Please list any topical or first aid items that are not to be used. Students in grades 6-8: Do you wish to be notified prior to administration of the above medicines? Yes I No (Circle one) (Yes means that if YOU cannot be reached your child will not receive medication. No means that your child will receive the above medication(s) at the discretion of school personnel) Students In grades 9-12: Students will receive the above medication(s) at the discretion of school personnel. I hereby authorize the physician, surgeon or dentist to administer any emergency treatment, procedure or medicine necessary and advisable. I also authorize the use of an ambulance, if necessary, to transport my child, I further agree to pay for all services provided for my child. If this is not satisfactory, please list specific emergency instructions in the event that you cannot be reached. Parent or Guardian Signature Date 25 HARMONY PUBLIC SCHOOLS HEALTH INVENTORY FORM Please fiJI in this form and return it to the school at the earliest possible date. The information given on this form wiJ/ enable the school staff to have a belter understanding of your child's health status. Student Name Date of Birth I Grade Sex: [J Male 0 Female Birth weight Disease Histo Disease Age Disease Age Disease Age o Asthma 0 Heart Disease 0 Sickle Cell Disease o Allergy 0 Kidney Disorder 0 Surgery/fractures o Blood Disorder 0 Orthopedic 0 TB contact o Convulsions 0 Poliomyelitis 0 Hearing loss o Diabetes 0 Rheumatic Fever 0 Vision loss o Epilepsy 0 Serious accident 0 Ilthis child has had any of the above conditions, did he/she receive medical care? 0 Yes 0 No Is he/she under treatment now? 0 Yes 0 No Please check any of the follOwing signs and symptoms you have recently observed: 0 Tires easily 0 Overweight 0 Frequent colds 0 Frequent sore throats 0 Earaches 0 Frequent stomach aches 0 Nail biting 0 Shyness 0 Does not get along with 0 Underweight 0 Frequent headaches others 0 Frequent nose bleeds 0 Fainting 0 Restlessness 0 Does not like school Has the child consulted a phYSician about the above symptoms? DYes ONo Has the pupil had a complete physical in the past year? OYes 0 No Is this child on any kind of medication? OYes 0 No tf so, explain? For what condition? Is this pupil under medical care at this time? DYes ONo Name of doctor or clinic: ______ Further comment: ______ Name of the Person completing this fonn Relation to the chHd I I Signature ~------__,_ Parent or Guardian Signature Dale 26 HARMONY PUBLIC SCHOOLS HOME LANGUAGE SURVEY (K-12) (English) Student Name Grade Date of Birth Phone: (_)__ - __ The Texas Education Gode requires schools to determine the language(s) spoken at home by each student This Information Is essentlal in order for sdlools to provIde meaningful instruction to all students. Please answer the folJovving questions. 1. What language is spoken in your home most of the time? o English 0 Spanish 0 Other (Specify) ______ 2. What language does the student (do you) speak most of the time? o English 0 Spanish D Other (Specify) ______ Grades PK-8 Grades 9 - 12 (Parant or Guardian) (Parant or Guardian or Student) (Date) (Date) Place of Birth (Country of Origin) Date of initial entry Into U.S. schools Number of complete academic City : ______years In a U.S. schooi:__ Country: ______Month___ Day __Year__ When your child lived outside tha U.S., did he or sha attand school regularly? (Check one.) o Yes, my child attended school regularty in all previous grades outside the U.S. o No, my child missed significant portions of one or more school years, as specified: Specify grade and time pertod, including month and year (example: Grade2, Jan. 2002 through May 2002). Do not include pertods of absence that lasted less then one month. Do not include regularty scheduled school hoiidays or vacations. Has your family worked In either the AGRICULTURE or FISHING Industry In the last 3 years? 0 Yes 0 No • ORIGINAL : Student Folder • YEUOW :School CopY • PINK : ESt Department 27 HARMONY PUBLIC SCHOOLS PERMISSION TO RELEASE SCHOOL RECORDS ~~-- (Studen~s Last Name) (Stllden~s First Name) (Date of Birth) By my/our signature below, I/we as parent(s) or legal guardian of the student whose name and date of birth is above give permission to the principal of ______School to release the following records to Harmony Schools. Records to be released: 1. Grades and academic records 2. Psychological assessment and records 3. Disciplinary records 4. Attendance records and medicallimmunization reports 5. Test results and/or evaluations Parent Date Witness Date Parent Date Witness Date NON-DISCRIMINATION STATEMENT: It is the policy of Hannony Schools to comply with all state and federal regulatlons regarding admission and not to discriminate during the admission and the lottery process on the basis of gender, national origin, ethnlcity, religion, disability, academic, artistic, athletic ability, or the district the child would otherwise attend. 28 HARMONY PUBLIC SCHOOLS PHOTO AND NAME RELEASE FORM I agree / disagree (circle one) to allow my child's photographs to be taken and/or names to be published to be used for Harmony Schools' publicity purposes. I understand that the photos and the names may be used for display, publication, video, websites, or by other media, such as local newspapers and/or television stations. I also agree that this permission will have no time limitations. I hereby certify that I am the parent/legal guardian of __-;=====____ in _ grade. (Student's Name) And I do give my consent on his/her behalf. Name of the parenUguardlan Signature of the parenUguardian Date NON·DISCRIMINA110N STATEMENT: It is the policy of Harmony Schools to comply with all state and federal regulations regarding admission and not to discriminate during the admission and the lottery process on the baSIS of gender, national origin, ethnicity, religion, disability, academic, artistic, athletic ability, or the district the chUd would otherwise attend. 29 HARMONY PUBLIC SCHOOLS SCHOOL MEDICATION AUTHORIZATION FORM Student Name Date of Birth -_/_ Grade/Section: __ Address Phones :L-)=:-__" L-)____,. L-)____ Home Mobile Work Emergency Phone :L-) Arclativ:e::-::or:-:a"f"'rie=n"'"d':Cs n=u=m:::b=.r: I, • parent or guardian of . hereby authorize Harmony Public Schools and their employees and agents, in my behalf and in my stead, to administer to my child (or to allow my child to self-administer, while under the supervision of the employees or agents of the charter school district), lawfully prescribed medication in the manner described below. I further acknowledge and agree that, when the lawfully prescribed medication Is so administered, I waive any claims I might have against the charter school district, Its employees and/or agents arising out of the administration of said medication. In addition, I agree to indemnify and hold harmless the School District, its employees and agents, either jointly or severally, from and against any and all claims, damages, causes of action or Injuries, induding reasonable attorney's fees and costs expended in defense thereof, Incurred or resulting from the administration of said medication. Parent's Signature Please list all medication that your child is taking at home; li.i:jjil.jtiU.::!!;3.i:Ni:i4-i.li.13~'i-"'~:n.;(",·i~1 (Use additional pages if needed) Diagnosis Dosage lime/Frequency ______Route of Administration: ______Type of Disease or Illness: ______If PRN, state frequency or Indication: ______ Must this medication be administered during the school day In order to allow the child to attend school? DYes DNa Are there any side effects to the medication? Dyes DNa If yes, specify: Is this drug covered by the psychotropiC drug law? Dyes DNa Other Recommendation: ______ Physidan's' Name (Print) Physician's Signature L_J ~-,-______Address Telephone Number 30 HARMONY PUBLIC SCHOOLS Student and Parent Acknowledgment Because you have chosen to be a student at Harmony, we anticipate that you will accept the rights of members of our community and your responsibilities to them, We ask you carefully read over and sign the contracts on this page, and as the year unfolds, do your best to behave in ways that will enhance your own and other's ability to learn, Harmony Schools shall foster a climate of mutual respect for the rights of others, Each student is expected to respect the rights and privileges of other students, teachers, and school personnel. The student's responsibilities for achieving a positive learning environment at school and/or school-related activities shall include the following: o Arrive school on time and stay until the designated time D Leave the school at the designated time o Attend all classes each day and be on time o Prepare for each class with appropriate materials and completed assignments o Attend any tutorial that is made mandatory by school officials o Make up assfgnments missed because of an absence D Dress according to the dress code adopted by each individual school o Know that the possession, use, and/or sale of illegal or unauthorized drugs, alcohol, and weapons are unlawiul and prohibited o Show respect toward others o Conduct yourself in a responsible manner o Know and obey all school rules in the Student Handbook o Cooperate with staff members in investigations of discipllnary matters CJ Seek changes!n schoo! policies and regulations in an orderly and responsible manner, through appropriate channels o Report threats to the safety of students and staff members as well as misconduct on the part of any other students or staff members to the building principal, a teacher, or another adult o Be familiar with and comply with the Acceptable Use Policy for Computers and Technology and understand that if access is nat desired, the parent and student may opt out Use school technology systems for school business purposes only and use school computers and related equipment approprtately o Report all observed or suspected technology security problems immediately to a teacher Student's Commitment I Promise, • I will follow the requirements of the school's student handbook, • I will set my goal to go to a college, • I will come to school every day dressed appropriately in my uniform. • I will attend 100% of each class. I am aware that missing 10% of class/school will result in a failing class/grade, • I will come to class on time with all necessary materials, • I will make good use of class time, asking permission to speak, doing my best on school work, turning in complete assignment and homework on time, and letting others do their work, • I will ask for help, in a courteous way, and at an appropriate time when I need it or do not understand, 31 • I will show careful regard for my property and the property of others, asking permission to borrow others' things and returning them promptly in a good condition. • I will show respect for myself and others, showing consideration for others' rights and feelings, not using profanity, intimidation, threats or uncomplimentary names for myself, fellow students, and all those who work at the school, guests, or families of Harmony school community. • I will be careful not to hurt myself or others physically by walking safely, not touching others, not fighting, not bringing any contraband to school, and not leaving school grounds without permission. It is important that every student understand the Code and be expected by his or her parent(s) or guardian(s) to follow the rules and regulations set forth in the Code. Please read and discuss the Code with your child. When you have done so, you and your child must sign this form and return it to the school. Signatures of parents and the student acknowledge receipt of a copy of the Code of Student Conduct and certify that they have read and discussed the Code. It is expected that students will accept their responsibilities as described in the Code of Student Conduct. Student's Name Grade Student's Signature Date Parent/Guardian's Name (as witness) Parent/Guardian's Signature Date Parent/Guardian's Name (as witness) Parent/Guardian's Signature Date ,..,..,-< >< ~ C"l ".. en ::r: ".. J> ~ -c ::0 :::0::0 = IT! ...... = I 0"" VI -f=-"" rTI= = -en NON~DISCRIMINA1l0N STATEMENT: It Is the policy of Harmony Schools to comply with all state and federal regulations regarding admission and not to discriminate during the admission and the lottery process on the basis of gender, national origin, ethnJdty, religion, disability, academic, artistic, athletic ability, or the district the child would otherwise attend. 32 i;,1ichael LVVHBarns CornmbS10nel Charter Renewal Contract May 23,2013 JUN - 5 2013 Mr. Oner U. Celepcikay, Board Chair Harmony Public Schools 4014 Creek Ridge Lane Missouri City, Texas 77459 Re: Charter Renewal Contract for Harmony Science Academy - Waco (CON 161-807) Dear Mr. Celepcikay: I am pleased to inform you that the charter renewal is approved for Harmony Science Academy - Waco with a contract ending date of July 31, 2021, After renewal, the charter contract shall consist of the following: • the representations and assurances made by the charter holder in the original request for application under the standard application system including all revisions made during the contingency process; • the original contract for charter, as signed by the charter holder and the State Board of Education; • any condition, amendment, modification, revision, or other change to the charter approved by the State Board of Education or the commissioner of education, including any prior renewal documents with revisions based on contingency responses; • the final renewal application received in spring 2010, on file with the Division of Charter School Administration, including any revisions required by the agency and any amendments to the charter made through the renewal application; and • all statements, assurances, commitments, and representations made by the charter holder in its application for charter renewal and its attachments or related documents, to the extent that these documents are consistent with those listed above. By accepting these renewal terms, the charter holder represents that it understands that the charter holder, including any and all governance, at whatever level whether appointed or elected, employees, agents, and volunteers, shall fully cooperate with every Texas Education Agency investigation and/or sanction deemed necessary by the commissioner based on authority and responsibility given to the commissioner in state or federal law, This means that Texas Education Agency staff may conduct confidential interviews of charter school personnel and contractors outside the presence of representatives of the charter school's administration and board and that failure to timely reply with reasonable requests for access to site, personnel, documents, or other materials and/or items is a material violation of the contract for charter. By accepting these renewal terms, the charter holder represents that it is understood by all parties that, if the charter holder loses its 501 (c)(3) tax exempt status for any period of time, through action of the Internal Revenue Service or any other action which renders the charter holder no longer an "eligible entity" within Mr. Oner U. Celepcikay, Board Chair Harmony Public Schools Page 2 the meaning of TEC §12.1 01 (a), the charter contract shall be rendered void, and it shall automatically return to the State Board of Education (SBOE) without any other action having to be taken by the SBOE or by the commissioner. Note that this contract is contingent upon legislative authorization and that the contract and the funding under state and federal law may be modified or even terminated by future legislative acts. Furthermore, state and federal laws and rules may periodically be adopted, amended, or repealed, and all such changes applicable to the charter holder or its charter school(s) may modify this contract, as of the effective date provided in the law or rule. Nothing in the charter contract shall be construed to entitle the charter holder to any privilege or benefit, including any funding, but in accordance with state and federal laws in effect and as they may in the future be amended. A contract term that conflicts with any state or federal law or rule is superseded by the law or rule to the extent that the law or rule conflicts with the contract term. To acknowledge acceptance of this renewed contract, the chair of the charter holder board must sign below and return the entire original document to: Texas Education Agency Division of Charter School Administration William B. Travis Building, Room 5-107 1701 North Congress Avenue Austin, Texas 78701-1494 The charter holder should keep a copy of the document for its files. Please contact the Division of Charter School Administration at (512) 463-9575 with any questions. L. Williams ('''';'''~issioner of Education MLW/kj cc: Dr. Soner Tarim, Superintendent I the undersigned hereby certify that the governing body of the charter holder has accepted and agreed to the charter renewal agreement for Harmony Science Academy - Waco as outlined in the foregoing letter and has authorized me to sign below. Agreed and Accepted: /)I/v:-J Oner U. Celepcikay, Board Chair Date Harmony Public Schools