Fillable School Enrollment Form O.A. Thorp Scholastic Academy Chicago

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School Enrollment Form O.A. Thorp Scholastic Academy Chicago

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Rev. 07/2014
Chicago Public Schools
School Enrollment Form
School Name__________________________________________________________________________
Student Info
rmation
Student’
s siblings’ names if
currently enrolled in CPS:
_________
__________________
_________
__________________
_________
__________________
________________
___
Student ID#
School Use Only:
Prevent duplicate student records. Search in SIM for an existing Student ID before
creating a new one.
_________
__________________ ______________________ __________________ ___________________
Last Name First Name Middle Name Generation (Jr., etc)
___________
___ _______________________________ _________________________________________
Gender Birth date
(mm/dd/yyyy) Registration Grade Level (when first entering CPS)
Personal, Immigrant, and
Refugee Information
To Parent/
Guardian:
CPS is required to keep a count of
immigrant students for Federal
and State Guidelines in order to
determine if additional resources
and services for students are
needed.
Note that this is not an inquiry on
citizenship status, and all
information will be kept
confidential.
Y / N _______________________________________________________
Birth Certificate on File Birth Verification Type
_________
_________________ ________________________________ ____________________________
* Birth Country Birth State Birth City
* Complete if student was not born in the United States (US) or one of its Territories:
Date of first enrollment in any US School: ____________________________
Full Years
completed school in US: _________________________________
Student has refugee status: Y / N Country of refugee:_____________________________________
School Use Only: Note that “Date of first enrollment in any US School” becomes a required field in SIM if “Birth
Country” is not the US or one of its Territories.
Student Address/Phone
Physical
(Home) Address
Mailing Address
(if different than Home)
_________
_________________________ ______ _________________ _________________ ___________
Street Number and Name Apt. City State Zip Code
_________
_________________________ ______ _________________ _________________ ___________
Street Number and Name Apt. City State Zip Code
Home Phone Nu
mber______________________________
Demographic,
Home Language,
Parent/Guardian Contacts,
Emergency/Health Information
Federal Ethnic and Race Categories: (Enter information into SIM from the Race and Ethnicity Survey form)
Home Language Survey: (Enter information into SIM from the Home Language Survey form)
Parent/Guardian Contacts: (Enter information into SIM from the Request for Emergency and Health Information form)
Emergency/Health Information: (Enter information into SIM from the Request for Emergency and Health Information form)
Enrollment
Enrollment
Status Codes:
01 – No Former School
02 – Chicago Public School
(to incl. Charter/Contract)
03 – Chicago Private School
04 – IL Public Schl, not Chicago
05 – IL Private Schl, not Chicago
06 – US Public Schl, not Illinois
07 – US Private Schl, not Illinois
08 – Not in USA
_______________________________________________________________ __________________________________
*School Transferring From
((if not a Chicago Public, Charter or Contract School) City and State
*Is the student in good standing? Y / N
(Instructions to school: for out-of-state public school or any private school students, a certification of “good standing” should be received
from the Parent/Guardian. Refer to CPS Policy 10-0623-PO1 for more information.)
Last Chicago
Public, Charter, or Contract School Attended _____________________________________________
Is the student receiving any type of Special Education services? Y / N
(Instructions to school: if yes, please notify the Case Manager.)
Student En
rolled by ____________________________________________________________________________
(Print Name and Relationship)
_________
________________________________________________ ________________________________
Signature of Parent/Guardian Date of Enrollment
School Use Only:
Enrollment Status Code (insert a # from the left) ______ Grade Level_______ Homeroom/Division #____________
O.A. Thorp Scholastic Academy
Rev. 01/2014 Chicago Public Schools
Request for Emergency and Health Information
School Name: _____________________________________________________________________________________
PARENTS/GUARDIANS: The school must have on file emergency information that can be used to contact you. Please print clearly. Whenever there is a
change in this information, immediately notify the school in writing.
___________________ __________________________________________________________________________________________ __________________
Student ID# Last Name First Name Middle Name Homeroom #
_______
_______________ ___________________________________________________________________________________ _____________________
Birth Date (mm/dd/yyyy) Student Home Address Student Home Phone #
Confidential Information Box 1
Complete this box only if (1) it reflects your child’s current living situation; OR (2) it reflects your living
situation if you are a youth not living with a Parent or Guardian. (Your answer will help school staff
with enrollment and may enable the student to receive additional services.) Check one box:
awaiting foster care placement in a car/park/other public place
doubled-up in a hotel/motel in a shelter in transitional housing
Confidential Information Box 2
Is there a current Order of Protection or No Contact
Order which concerns this student? Yes No
School Note: If any box is checked, see the CPS Policy 702.5.
Parent/Guardian and Emergency Contact Information: Add extra contacts on the back of this form, if needed.
Parent/Guardian Contact Parent/Guardian Contact
Contact Name
Relationship to Student
Check all that apply:
Lives With Gets Mailings
Emergency Permission to Pickup
Lives With Gets Mailings
Emergency Permission to Pickup
Home Address, if different
from student’s
Home Phone Number, if
different from student’s
Cell Phone Number
Email Address
Name and Address of
Employer
Work Phone Number
* Communication Language
* CPS communicates via phone calls. Select the language that should be used to communicate with you. Languages available for mass communication at this time
are English and Spanish (note: other languages upon availability).
List the name of a relative or neighbor who can also be notified in an emergency and has permission to pick up the student:
_______
__________________________________________________________________________________________________________________________
Name Home Address Telephone # Relationship
Family Doctor
’s Name, Address, and Phone Number: I authorize you to call my family doctor, if necessary, in an emergency.
____________________________________________________________________________________________________________________________________
Student Health
Insurance: (select only one of the three)
Illinois Medical Card/All Kids: provide student’s medical ID # __________________________________________(9-digit number located on back of card)
No Insurance: are you interested in applying for the Illinois Medical Card/All Kids? Yes No
Private/Employer Health Insurance: no additional information needed
Children of Military Personnel
(optional)
As the Parent or Guardian, are you a member of a branch of the armed forces of the United States? Yes No
If yes, are you either deployed to active duty or expect to be deployed to active duty during the school year? Yes No
I certify
that the information on this form is correct:
____________________________________________________________________________(Parent/Guardian Signature)___________________________(Date)
School Note: If “Yes,” follow CPS Policy 704.4
procedures. Enter information in Legal Alert field
and update contact information, as needed, in SIM.
O.A. Thorp Scholastic Academy
Revised: April 15, 2015
Office of Student Health and Wellness
42 West Madison • Chicago, Illinois 60602
Telephone: 773-553-3520 • Fax: 773-553-1883
Office Use Only
Reviewed by:
Follow up:
Documents received:
Student Medical Information 2020/21 School Year
INFORMATION MUST BE UPDATED AND SUBMITTED ANNUALLY AT THE BEGINNING OF THE SCHOOL YEAR
PLEASE PRINT ALL INFORMATION and RETURN FORM TO SCHOOL
OA THORP SCHOLASTIC ACADEMY
Student Name: __________________ Date of Birth: ________________ Grade: ___________
Student ID: ____________________ Medicaid Number: _________________________
To ensure the safety of your child during the school day, extracurricular activities, on any field trip, and
when being transported by CPS it is important that the school is aware of any health conditions that may
impact your child. We are asking you to please complete this form. For confidentiality purposes, this
information will only be shared with relevant CPS staff. Thank you for your cooperation in this important
matter.
Please check below if applicable:
□ Food Allergies: (Type)
□ Other Allergies: (Type) ___
□ Asthma
□ Diabetes: Type 1 □ Type 2 □
□ Seizures
□ Other Medical Condition
□ My child has NO allerg
ies, medical conditions and/or does not
take any medications during school hours
□ My child has a primary healthcare provider (e.g., Doctor, Nurse
Practitioner, Physician Assistant, etc.)
For the medical condition identified above which requires prescribed medication during school hours,
please provide written verification from your healthcare provider with diagnosis, type of medication,
dosage, and time to be given. An Emergency Action Plan (Allergy, Asthma, or Diabetes) can also be
requested from your healthcare provider. Your child may qualify for a 504 Accommodation Plan due to
his/her condition. Please make sure you follow up with your school nurse and/or case manager once
you have submitted this form.
Parent Name: (Please Print): ______________________________ Date: __________________
Parent Signature: _______________________________________
Phone Number: ______________________________ Email: ___________________________
Educate · I
nspire · Transform
Complete this Home Language Survey at the student’s initial enrollment in a Chicago Public School.
This form must be kept in the student’s folder.
School: Room: Unit: Area:
Student Name: Student ID No.:
English
1. Is a language other than English spoken in your home?
No Yes (Language)
2. Does the student speak a language other than English?
No Yes
(Language)
IMPACT REGISTRATION PROCESS
(For Office use only)
The Non-English language identified on either
question is the
Home Languag
e.
If two different non-English languages are identified,
enter the language
identified in question 2 as the
Home Language.
Enter ENGLISH as a Home Language ONLY
when
both questions
are answered
no.
If the answer to either question is yes, the law requires the school to
assess your child’s English language proficiency.
Spanish Polish
1. ¿Se habla algún otro lenguaje que no sea inglés en su
hogar?
1. Czy językiem innym niź angielski mówi się w domu?
No Sí (Lenguaje) Nie Tak (język)
2. ¿Habla el estudiante un lenguaje que no sea el inglés? 2. Czyt uczeń mówi innym językiem niż angielski?
No Sí (Lenguaje) Nie Tak (język)
Si la respuesta a cualquiera de las preguntas es “Sí”, la ley requiere
que la escuela evalúe la fluidez de su niño en el idioma inglés.
Jeśli udzielili Państwo twierdzącej odpowiedzi na którekolwiek z powyższych
pytań, przepisy wymagają, aby szkoła sprawdziła poziom znajomości języka
angielskiego waszego dziecka.
Chinese Arabic
如果你在兩個問題中之任一項的答案是 “是”, 則法律規定校方
要測試貴子女的英語通悉度。
ﻢﺘﺤﯾ نﻮﻧﺎﻘﻟا نﺈﻓ ﻦﯿﻟاﺆﺴﻟا ﻦﻣ يأ ﻲﻠﻋ ﻢﻌﻧ ﺔﺑﺎﺟﻹا ﺖﻧﺎﻛ اذإ ﻲﻠﻋ
ﺔﯾﺰﯿﻠﺠﻧﻻا ﺔﻐﻠﻟا ماﺪﺨﺘﺳا ﻲﻓ ةءﺎﻔﻜﻠﻟ ﻢﻜﻨﺑا ﻢﯿﯿﻘﺗ ﺔﺳرﺪﻤﻟا.
Bosnian/Croatian/Serbian Urdu
Chicago
Public
Schools
Ukoliko ste na bilo koje od ovih pitanja odgovorili sa “Da”, škola
će biti zakonski dužna da procijeni nivo znanja engleskog jezika
kod vašeg djeteta
Signature of School Official Date Signature of Parent/Guardian Date
Office of
Language
and
Cultural
Education
Revised:
Mar. 2009
Notes:
If the parent/guardian does not speak English and the school does not have staff who speaks the parent/guardian’s language,
identify the langu
age spoken
by the parent/guardian through any assistance available in
the school.
If exact name of the language cannot be determined, enter “Other” as a temporary entry. The exact language must be
determined with
in two wee
ks after the enrollment. Assistance from Area Compliance
Facilitators is available.
Questions or concerns, contact your Area Compliance Facilitator.
O.A. Thorp Scholastic Academy
29301
ISP
ENGLISH
Student’s Name:
Gender:
Birth Date:
INSTRUCTIONS: Please answer the questions below. Both questions must be
answered. Part A asks about the student's ethnicity and Part B asks about the
student's race. If you decline to respond to either question, the school district is required
to provide the missing information by observer identification.
Part A.
Is this student Hispanic/Latino?
(A person of Cuban, Mexican, Puerto Rican,
South or Central American, or other Spanish culture or origin, regardless of race.)
Choose only one.
□
No, not Hispanic/Latino
□
Yes, Hispanic/Latino
The question above is about ethnicity, not race. No matter which answer you selected, continue
and respond to the question below by marking one or more boxes to indicate what you consider
this student's race to be.
Part B.
What is the student's race? Choose one or more.
□
American Indian or Alaska Native
(A person having origins in any of the
original peoples of North and South America, including Central America, and who
maintains tribal affiliation or community attachment.)
□
Asian
(A person having origins in any of the original peoples of the Far East,
Southeast Asia, or the Indian subcontinent including, for example, Cambodia,
China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand,
and Vietnam.)
□
Black or African American
(A person having origins in any of the black
racial groups of Africa.)
□
Native Hawaiian or Other Pacific Islander
(A person having origins in any
of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)
□
White
(A person having origins in any of the original peoples of Europe, the
Middle East, or North Africa.)
O.A. Thorp Scholastic Academy - 29301
Race and Ethnicity Survey
OA Thorp Scholastic Academy
Media Consent Form and Release 2020-21
Student Name: __________________________________ Rm#: ____________________
Dear Parent/Guardians,
At OA Thorp Academy, we make extensive use of our website, tv monitors and thorp tv to communicate events,
news and school activities. Please give us your consent in order for us to use pictures of your child and their
classrooms. We will never publish an identifying photos of children on our website. If you have any questions, or
concerns please feel free to call the office.
Thank you—Mr. Toledo
_________________________________________________________________________
Consent/Release
I hereby
consent to have my child photographed, digitally recorded, video taped, audio taped and/or interviewed
by the Board of Education of the City of Chicago (the “Board”) or the news media when school is in session or
when my child is under the supervision of the Board. Further, I consent for these photos, digital recordings, video
tapes, audio tapes and/or interviews to be shared with third parties who have received written approval from the
Office of Communications. I understand in the course of the above described activities that the Board might like to
celebrate my child’s accomplishments and work. Therefore, I further consent for the Board’s release of
information on my child’s name, academic/non-academic awards and information concerning my child’s
participation in school-sponsored activities, organizations and athletics.
I also consent to the Board’s use of my child’s name, photograph or likeness, voice or creative work(s) on the
Internet or on a CD or any other electronic/digital media or print media.
As the child’s parent or legal guardian, I agree to release and hold harmless the Board, its members, trustees,
agents, officers, contractors, volunteers and employees from and against any and all claims, demands, actions,
complaints, suits or other forms of liability that shall arise out of or by reason of, or be caused by the use of my
child’s name, photograph or likeness, voice or creative work(s), on television, radio or motion pictures, or on the
Internet, or on a CD, or any other electronic/digital media or print media.
It is further understood and I do agree that no monies or other consideration in any form, including reimbursement
for any expenses incurred by me or my child, will become due to me, my child, our heirs, agents, or assigns at
any time because of my child’s participation in any of the above activities or the above-described use of my child’s
name, photograph or likeness, voice or creative work(s).
I understand that I may cancel this release by providing written notice to the principal. I also understand that this
release is valid for one school year, including the following summer.
Instructions: Check Box #1 or Box #2
1.
I consent as outlined in the above consent/release section.
2. I DO NOT consent as outlined in the above consent/release section.
_____________________________________________ _____________________________________________
Signat
ure of Parent/Guardian/Student if age 18 or older Printed Name of Parent/Guardian/Student if age 18 or older
_____________________________________________
Date
I understand that I have the right to inspect and copy my student’s records, challenge the contents of such
records; and limit my consent to the designated records or designated portions of information within the records.
04/15/20
Notification Letter to Parents
“Application for School Bus Service”
Dear Parent:
RE: Student Transportation Procedures – School Year 2020-2021
School bus service is provided to eligible students enrolled in specified programs and schools that meet the transportation eligibility
standards approved by the Board of Education of the City of Chicago. This letter is provided as a reminder that the Application
for School Bus Service – White Form" must be returned to the school office so the school can enter the request by June 19, 2020
If you complete any of the optional transportation forms below, please return them to the school with the White Form. After review
and approval, the school will forward the forms to Student Transportation Services (STS) for final review and approval in
conjunction with routes that will be developed during the summer for the beginning of the new school year.
Mandated Form:
“Application for School Bus Service – White Form”: Parents of students currently enrolled and receiving bus service as well
as students enrolling for next school year and desiring bus service are required to complete the form annually. The form must be
submitted to the school by June 19, 2020, if bus service is desired for the start of the next school year.
Optional Forms
Parents may also complete and submit the following transportation request forms, if applicable, to the schools along with the
“Application for School Bus Service – White Form”. Any optional transportation forms received by schools after the June 19, 2020
deadline may still be forwarded to our office; however, we do not guarantee the requests will be processed and approved changes
made by the first day of the school year.
• “Sibling Transportation Request – Yellow Form”: Parents/guardians may use this form to request transportation for their
children who are not eligible for bus service but who attend the same school as a sibling who is eligible for bus service.
Siblings must also have the same parents/guardians and live at the same address to qualify.
REMINDER: once siblings have been approved for transportation, this form no longer needs to be submitted each school
year - as long as the eligible student and the approved siblings are still enrolled at the same school, live at the same address,
and have the same guardian. If the students are new to the school, the parent/guardian should complete a new Sibling
Transportation Request form and submit it to the school for processing. The request does not follow the students if they
transfer to a new school.
• “Chicago Park District – Park Kids Program Request – Green Form”: Parents/guardians may request bus service in the
afternoon to an approved Chicago Park District-Park Kids Program. Please be aware that service to a Park Kids Program is
not funded by the Chicago Public Schools, therefore, approval is limited to the policies outlined at the top half of the form.
Parents are responsible to make other arrangements for their children to get to the Park Kids Program until they are notified
their request has been approved.
REMINDER: In order to expedite the review process of Park District requests, we have “Pre-Approved” some parks for
schools that traditionally have students participating in Park Programs. Please ask the school which parks have been pre-
approved for your school. The service to the “Early Start” parks will begin Monday, September 21, 2020. Families may still
opt to apply for bus service to Chicago Park District programs that are not on the Pre-Approved list. Those forms will be
processed after the first day of school and service to those parks will begin on Monday, September 28, 2020.
• “Day/Child Care Bus Stop Change Request – Blue Form”
This form can be completed by parents/guardians of Diverse Learner students eligible for bus service who are
requesting a change from home pickup and drop-off to a day/child care location.
• “School Bus Stop Change Request – Gray Form”: Students are generally assigned to their neighborhood elementary
school as their bus stop. Parents may request a change in the assigned bus stop location to another CPS school site
location. Parents/guardians of regular education students are to use this form to request a stop change to a CPS school site
that is close to a day/child care provider.
Please contact the school or our office to see if the following form is applicable for your child:
• Application for Determination of a Serious Safety Hazard
• Prior-approved Safety Hazards are reviewed yearly and may be reversed if no longer appropriate
Completed forms should be returned to the school office (do not send forms directly to our office). Please contact the school office
for additional information concerning bus service. All student transportation eligibility standards, forms, policies and procedures
are available at the school office or on the CPS web site:
http://www.cps.edu/Programs/Pages/Transportation.aspx
Thank you.
Application For School Bus Service Revised: 04/15/20
“WHITE FORM”
Chicago Public Schools –Student Transportation Services
Application for
School Bus Service
School Year 2020-2021 Designated Programs
TRANSPORTATION IS NOT GUARANTEED, IN ORDER TO QUALIFY YOU MUST LIVE A
RADIUS OF 1.6 MILES FROM THE SCHOOL AND NOT BEYOND 6 MILES.
Notice: Students participating in specified programs at identified Chicago Public School sites are eligible for school bus service in accordance
with published policies. The parent and/or legal guardian of each student attending the Chicago Public Schools and requesting school bus
service to a school with bus service for the next school year and/or completing any transportation request form must complete this application by June
19, 2020.
Forms received after this date will be processed, but transportation on the first day of school is not guaranteed. Parents may request bus
service at any time during the school year but only those programs authorized to receive bus service by the Board of Education shall be
approved. This form is not applicable for summer school bus service.
Responsibility: It is the parent’s/guardian’s responsibility to provide adult supervision during a child’s walk to and from the assigned
pickup/drop off location and until the bus arrives. Generally, school bus service is provided to selected programs and when the student lives
between 1.5 and 6 miles from their attending school. Neighborhood schools are normally assigned as pickup/drop off locations for most
students. Students with special needs who are eligible for bus service will receive home pick up if required by their Individualized Education
Program (IEP);
parents/guardians of such students are to meet the bus at the curb for pick-up/drop-off. Additionally, parents/guardians
are responsible to have the child ready and at the assigned stop location 10 minutes prior to the scheduled pickup time.
Parents must acknowledge that they have reviewed the eligibility standards for bus service and that their child/children will use the
bus service
on a regular basis. Lack of regular use can cause the assigned school site stop location to be removed from the
route for the remainder of the school year.
Schools and programs approved for school bus service in addition to the current student eligibility policies are available at all
Chicago Public School locations and on the CPS web site: http://www.cps.edu/Programs/Pages/Transportation.aspx
(Please Print or Type – All Fields Must Be Completed)
School of
Attendance (Name):
Unit
No.:
Student Name
Student ID
Grade
Current Legal Home Address:
Home
Phone:
Cell
Phone:
Other
Phone:
Home Address (after 07/01/18 if moving):
Home
Phone:
Cell
Phone:
Other
Phone:
Name of Parent or
Legal Guardian:
Email
Address:
Request for Bus Service: As a parent and/or legal guardian of the above noted child/children, I request school bus
service for the 2020-2021 school year and have read and agree to the eligibility policies for bus service.
Parent/Guardian Signature (MANDATORY):
Date of Request:
Check selection that applies: ( ) New Enrollee ( ) New Address for SY 20-21 ( ) No Change for SY 20-21
School Action:
If the student is presently enrolled at the school, receiving bus service, and there is no change in the bus service, no action is
required. Do not change or enter a new transportation request in ASPEN. Note: half-day students with transportation must be
verified each school year and updated if the homeroom has changed.
If the student is newly enrolling, enter the student transportation request in ASPEN. For students who will have a new home
address for school year 2020-2021, the new address cannot be entered into ASPEN until after July 1. No new request is required
if the student has an active transportation request.
Keep this form at the school. Do not send a copy to Student Transportation Services unless specifically requested.
O.A. Thorp Scholastic Academy 29301
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School Enrollment Form O.A. Thorp Scholastic Academy Chicago

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