Agora Enrollment Forms Packet PDF Details

The Agora Enrollment Forms Packet is now available to help parents through the process of enrolling their children in our program. This packet contains important information about our school, as well as the enrollment forms that must be completed in order to register a student. We encourage all parents to read through the packet carefully, and to contact us if they have any questions.

Here are some details you might want to look at before you start using the agora enrollment forms packet.

QuestionAnswer
Form NameAgora Enrollment Forms Packet
Form Length8 pages
Fillable?Yes
Fillable fields139
Avg. time to fill out29 min 52 sec
Other namesMailInForm agora charter school pittsburgh 866 529 0166 form

Form Preview Example

Agora Cyber Charter School

Enrollment Processing Center

2300 Corporate Park Drive

Suite 200

Herndon, VA 20171

Ph. 1.866.548.9451

Fx. 1.866.529.0166

www..k12.com/agora

Enrollment Forms Packet (EFP)

Please review the information below. Based on your student(s) grade and applicable circumstances, you are required to sub- mit documentation in order to complete this step in the enrollment process. You can fax, scan and email, or mail the required paperwork .

Important Note: Please send copies, do not mail the original documents

 

Fax (preferred):

Scan and Email:

Mail:

 

1-866-529-0166

agorafax@k12.com

Agora Cyber Charter School

 

 

 

 

2300 Corporate Park Drive

 

 

 

 

Suite 200

 

 

 

 

Herndon, VA 20171

 

 

 

 

 

 

Required For?

Item

Description

 

Provided

 

by?

 

 

 

 

 

 

 

 

 

 

Proof of Age

Oficial Birth Certiicate (not the hospital issued certiicate)

Provided by

 

you

 

 

 

 

 

 

 

 

 

 

Please submit one of the following:

 

 

Proof of Residency

Current Utility Bill (gas, water, electric, sewage, cable or land line phone) with service address OR

Provided by

 

Valid Pennsylvania Driver’s License OR Department of Transportation ID OR Mortgage statement/

you

 

 

 

 

Current Lease with signature OR Valid Vehicle Registration OR Property tax bill OR Deed

 

 

 

 

 

 

 

Immunization Record

Current Immunization Record OR Immunization Exemption Form

Provided by

 

you

 

 

 

 

 

 

 

 

 

 

Charter School Student

By illing out this form, you have indicated your decision for your child to attend Agora and that

Provided in

 

Enrollment Notiica-

 

your child will not be enrolled in another school while attending Agora.

this packet

 

tion Form

Required for all

 

 

 

 

 

 

 

 

Please note that you should only write an “X” in one of the blanks to indicate if your student WAS/

 

Students

Notiication of Offense

Provided in

 

IS or WAS/IS not expelled or suspended. Only ill out the boxed section if it applies to your student.

 

Form

this packet

 

The form must be signed and submitted for all students.

 

 

 

 

Home Language

Please read the directions for this form to ensure you answer the questions correctly

Provided in

 

Survey

this packet

 

 

 

 

Face-to-Face Enroll-

 

 

Provided

 

ment Information Ses-

This form serves as conirmation the parent or guardian attended the Face to Face Enrollment Ses-

during

 

sion Acknowledgement

sion.

 

Orientation

 

of Attendance

 

 

Session

 

 

By illing out this form, you are giving our school permission to request your student’s oficial re-

Provided in

 

Release of Records

cords from their previous school after the approval process. If your child is enrolling in Kindergar-

 

this packet

 

 

ten or was Homeschooled please indicate it on the form, ill out the top portion and sign it.

 

Required for all 1st

Report Card

Please submit your student’s most recent report card.

Provided by

-9th Grade Students

you

 

 

 

 

 

 

 

Required for all 10

 

You will need to request an unoficial transcript from your student’s current school, which will

Provided by

Unoficial Transcripts

show your student’s academic standing. This is required in order to place all 10th - 12th graders.

-12th Grade Students

you

 

Once your student is approved, we will receive the oficial transcript directly from the school.

 

 

 

Required for Prior

Afidavit, Educational

This is the form that you would have iled with the district registering your child as a home

Provided by

Home School Stu-

Objectives and Evalu-

schooled student.

you

dents

ation

 

 

 

 

 

 

 

Required for student

IEP

A copy of your student’s current IEP (Individualized Education Plan). Because the IEP expires

Provided by

yearly, please submit the current IEP.

 

with an IEP or other

 

you

Special Education

Evaluation Report

The Evaluation Report is valid for 3 years. If you do not have a copy of your student’s ER, you

Provided by

needs

can request a copy from your student’s current school.

you

 

Required for students

504 Accommodation

A copy of your student’s current 504 Accommodation Plan. Because the 504 expires yearly, please

Provided by

that have a 504 plan

Plan

submit the current 504.

you

 

 

 

 

 

Charter School Student Enrollment Notification Form

For School Year 1-1

Warning: A child enrolled in another public school or a nonpublic or private school cannot, at the same time, enroll in a charter school, but is permitted to complete an application for enrollment while enrolled in other school.

Name of Charter

School:

 

Agora Charter Cyber School

 

Address:

 

995 Old Eagle School Road Suite 315

 

 

 

Wayne, PA 19087

 

Charter School

 

 

 

 

 

Contact Person:

Business Office

 

 

 

 

 

 

 

Email

 

Telephone:

877-362-4672

 

Address:

enrollment@agora.org

 

 

 

 

 

 

 

I. Student Information:

Last

First

 

 

 

 

 

Name:

 

Name:

 

 

 

MI:

 

Home

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

State:

 

 

Zip Code:

 

County:

 

 

Telephone:

 

 

 

 

 

 

Mailing Address (If

 

 

 

 

 

 

 

 

 

 

Different From

 

 

 

 

 

 

 

 

 

 

Home Address)

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

State:

 

 

Zip Code:

 

Date Of Birth:

 

Age:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

II. School District of Residence and Former School Information

School District of

Residence:

Former School Information (Other Than Pre-School):

 

 

 

 

 

 

 

 

 

 

 

Public

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

School

 

 

Charter School

 

 

Home School

 

 

 

Nonpublic School

 

Student Not Enrolled in School Preceding Enrollment in Charter School Because:

 

 

 

Entering

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Kindergarten

 

 

Re-Enrolling Dropout

 

 

Other

 

 

 

Name of Former School:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address of Former School:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Withdrawal Date From Former

 

 

 

 

 

 

 

 

 

 

Previous Grade:

 

School:

 

 

 

 

 

 

 

 

 

 

Was Your Child Receiving Special Education Services Based On An Iep?

 

 

 

Yes

 

No

If Yes, Do You Have The Child’s Special Education Records (Iep)?

 

 

 

 

Yes

 

 

No

Page 1 of Charter School Student Enrollment Notification FormPDE 7/2002 Instructions for this can be found at www.pde.state.pa.us. Under the K-12 Schools folder, click on Public Schools, then Charter School, then Reporting.

III. Parent/Guardian Information:

 

 

Both

 

Both Parents

 

 

Mother

 

Father

Child Lives With:

 

Parents

 

Alternately

 

 

Only

 

Only

 

 

Legal

 

Foster

 

 

 

 

 

 

 

 

Guardian

 

Parents

 

Other Adult

 

 

 

Special Custodial Court Instructions:

 

 

 

 

 

 

 

 

 

(If Yes, Please Provide a Copy of Court

 

 

 

 

 

 

 

 

 

Order.)

 

 

 

Yes

 

 

No

 

 

Complete Parent/Guardian Name and Address Information As Applicable

Father’s Name

Address:

City:

 

 

State:

 

 

Zip Code:

 

Home Telephone:

 

Work Telephone:

 

 

 

 

Mother’s Name

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

City:

 

 

State:

 

 

Zip Code:

 

Home Telephone:

 

Work Telephone:

 

 

 

 

If The Student Is Not Living With Parents, Please Complete This Section.

 

Guardian’s Name

Or

 

Foster Parent’s Name

Or

 

 

Other Adult Name

Name:

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

State:

 

 

Zip Code:

 

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

Signature of

Parent/Guardian:Date:

IV. To Be Completed By Charter School:

Verification of Date of Birth:

 

Birth Certificate

 

 

Other

 

 

 

Proof of

Mortgage

 

 

 

 

Utility

 

 

 

Residency

 

 

Statement

 

 

Lease

 

 

Bill

 

 

Other

 

Official Enrollment Date:

 

 

 

 

 

Anticipated Date of Attendance:

 

 

 

Grade Student Is Entering:

Signature of Charter School

Representative:

Page 2 of Charter School Student Enrollment Notification Form

PDE 7/2002

2300 Corporate Park Drive

Suite 200

Herndon, VA 20171

Toll Free: 87736 AGORA (3624672)

Office: 6102548218

Fax: 8665290166

www.agora.org

NOTIFICATION OF OFFENSE INVOLVING WEAPONS, ALCOHOL OR DRUGS, INFLICTION OF INJURY TO ANOTHER PERSON, OR ANY ACT OF VIOLENCE, COMMITED ON SCHOOL PROPERTY

Parental Registration Statement

Student Name

Date of Birth

 

Grade

 

 

Parent or Guardian Name

 

_______________

Home Address

 

__________

 

Home Phone

 

 

Alternate Phone_____

__________________

 

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

Please check the appropriate box below and sign: (if you indicate “Yes” please complete the remainder of this form and sign)

I hereby swear or affirm that

YES, My child has been previously suspended or expelled OR currently is suspended or expelled from any public or private school of this Commonwealth or any other state for an act or offense involving weapons, alcohol or drugs, or for the willful infliction of injury to another person or for any act of violence committed on school property.

NO, My child has not been previously suspended or expelled OR currently is suspended or expelled from any public or private school of this Commonwealth or any other state for an act or offense involving weapons, alcohol or drugs, or for the willful infliction of injury to another person or for any act of violence committed on school property.

I make this statement subject to the penalties of 24 P.S. §13-1304-A(b) and 18 Pa. C.S.A. §4904, relating to unsworn falsification to authorities, and the facts contained herein are true and correct to the best of my knowledge, information and belief.

**Please complete if your child has been or is presently suspended or expelled from another school** My child was suspended expelled from the following school:

Name of the school: __________________________________________ Telephone:________________________________

School Address:____________________________________________________________________________________________

Suspension/ Expulsion Start Date: _____________________________________ (MM/DD/YYYY)

Suspension/ Expulsion End Date: ______________________________________ (MM/DD/YYYY)

(Please provide additional schools and dates of expulsion or suspension on back of this sheet.)

Reason for suspension/expulsion. (Please check all that apply) o Offense involving weapons

o Offense involving alcohol o Offense involving drugs

o Willful infliction of injury to another person

o An act of violence committed on school property o Other Additional comments:

_________________________________________________________________

(Parent or Guardian Signature)

(Date)

Thank you for completing the following information on the Home Language Survey. This is information the Pennsylvania Department of Education requires be collected by all educational entities during initial enrollment.

The first three questions relate to your child’s first language. Please do not include languages learned in school. As part of the enrollment process, this information will assist us in identifying any supports that your child may need.

Question four asks if your child has attended school in the United States for any three years. These years do not have to be consecutive. Please complete the name of school, state and dates attended for the most current schools your child has attended in the United States. These include preschool, private schools and home schooling.

If someone other than the parent completed the form please note where it indicates. Please leave blank otherwise.

The form is completed by the parent/guardian signing where indicated.

We thank you in advance for taking the time to complete this form.

________________________________________________________________________

HOME LANGUAGE SURVEY*

The Office of Civil Rights (OCR) requires that school districts/charter schools/full day AVTS identify limited English proficient (LEP) students in order to provide appropriate language instructional programs for them. Pennsylvania has selected the Home Language Survey as the method for the identification.

School District:

Date:

School:

 

Student’s Name:

Grade:

1.What is/was the student’s first language? __________________________

2.Does the student speak a language(s) other than English? (Do not include languages learned in school.)

Yes No

If yes, specify the language(s): ____________________________________

3.What language(s) is/are spoken in your home? ______________________

4.Has the student attended any United States school in any 3 years during his/her lifetime?

Yes No

Name of School

State

Dates Attended

______________________

_____________

__________________

______________________

_____________

__________________

______________________

_____________

__________________

Person completing this form (if other than parent/guardian): Parent/Guardian signature: ______________________ Date: _____________

*The school district/charter school/full day AVTS has the responsibility under the federal law to serve students who are limited English proficient and need English instructional services. Given this responsibility, the school district/charter school/full day AVTS has the right to ask for the information it needs to identify English Language Learners (ELLs). As part of the responsibility to locate and identify ELLs, the school district/charter school/full day AVTS may conduct screenings or ask for related information about students who are already enrolled in the school as well as from students who enroll in the school district/charter school/full day AVTS in the future.

Agora Cyber Charter School

Enrollment Processing Center

2300 Corporate Park Drive

Suite 200

Herndon, VA 20171

Ph. 1.866.548.9451

Fx. 1.866.529.0166

www..k12.com/agora

Release of Student Records

Please accept this document as formal approval for the release of all official school records (including the record of transcripts, testing information, special education, health and immunization records).

Student Information

Student’s Full Name:

 

first

middle

last

 

 

Student’s Date of Birth:

 

 

 

 

 

 

Student’s Legal Address:

 

 

 

 

 

 

 

street

 

apt #

 

 

 

 

 

 

 

city

county

state

zip

 

Home Phone:

 

 

 

 

 

 

 

Homeschooled or Never Previously Enrolled in School (Fill out only if applicable)

Check below if applicable:

oStudent was always previously homeschooled

oStudent is enrolling in Kindergarten

Prior School Information

NameofPriorSchool:

School’s Address:

 

street

 

 

city

 

county

state

zip

School’s Phone:

 

 

 

 

Sign and Date below

Name of Parent or Legal Guardian:

 

first

last

Parent/Guardian’s Signature:

 

 

Date:

SCHOOL OFFICIALS ONLY:

SCHOOL OFFICIALS ONLY:

SCHOOL OFFICIALS ONLY:

Send student records to: Agora Cyber Charter School

Send student records to:

Virginia Virtual Academy

Send student records to:

995 Old Eagle School Road

Washington Virtual Academies

 

2300 Corporate Park Drive, Suite 200

Suite 315

1584 McNeil Street, Suite 200

Herndon, VA 20171

Wayne, PA 19087

DuPont, WA 98327

Student’s Name:

Student’s Home Phone:

19

2300 Corporate Park Drive

Suite 200

Herndon, VA 20171

Toll Free: 877-36 AGORA (362-4672)

Office: 610-254-8218

Fax: 866-529-0166

www.agora.org

Acknowwledgment of Legal Guardianship

Student Name: ____________________________________________

Date of Birth___________________________

I understand that false statemennts herein are made subject to the penalties of the crimes code, chapter 49, subchapter A, sections 4901 to 4904, relating to perjury and falsification in official matters.

Please complete ONE of the following:

1.I (We) am the NATURALL parent(s) of the named student. I (We) retain custodial rights to enroll the student in the Agora Cyber Charter School.

Mother Name ___________________________________________________________________

Signature ________________ __________________________ Date______________________

Father Name ___________________________________________________________________

Signature ________________ __________________________ Date______________________

2.I am the court appointed guardian, adoptive parent or foster parent of the named student. I will provide the appropriate documentation to enroll the student in the Agora Cyber Charter School.

Court Ordered Custoody Agreement

Adoption Decree

Verification of Fosteer Care Placement (such as a letter from the appropriaate agency)

Other Appropriate Legal Documentation

Name________________________________________________

Signature ___________________________________________ Date_____________________

Relationship to student_____________________________________

3.I am the primary care givver of the name student. I will provide the appropriiate documentation to enroll the student in the Agora Cyber Charter School.

If you are not the leggal guardian of the named student but are supporting the student gratis, (without personal coompensation or gain), will assume all personal obligatiions for the student relative to school re quirements and intend to keep and support the student continuously and not merely through the school term, you are required to submit the Agora Cyber Charter School Sworn and Notarized Statement. Please request this form by contacting 1-866- 548-9452.

Care GiverName_______ ___________________________________________ _______________

Signature ___________________________________________ Date_______________________

Relationship to student_____________________________________

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Agora Enrollment Forms Packet gaps to fill in

Make sure you type in the crucial data in the Last Name: Home Address:, City:, County: Mailing Address (If, City:, Date Of Birth:, First Name:, MI:, State:, Zip Code:, Telephone:, State:, Zip Code:, Age:, School District of Residence:, and Former School Information (Other field.

stage 2 to filling out Agora Enrollment Forms Packet

The application will request particulars to automatically fill in the area Student Not Enrolled in School, Re-Enrolling Dropout, Other, Name of Former School: Address of, Previous Grade:, Withdrawal Date From Former School:, Was Your Child Receiving Special, Yes, Yes, Page 1 of Charter School Student, and PDE 7/2002.

Entering details in Agora Enrollment Forms Packet stage 3

In section III, Child Lives With:, Both Parents Legal Guardian, Both Parents Alternately Foster, Special Custodial Court, Other Adult, Yes, Mother Only, Father Only, Father’s Name Address: City: Home, State:, Zip Code:, Work Telephone:, State:, and Zip Code:, state the rights and responsibilities.

part 4 to filling out Agora Enrollment Forms Packet

Finish by taking a look at the next areas and filling them in as needed: If The Student Is Not Living With, Foster Parent’s Name, Guardian’s Name Name: Address:, Other Adult Name, Zip Code:, State:, Signature of Parent/Guardian:, Birth Certificate, Mortgage Statement, Date:, Other, and Utility Bill.

step 5 to filling out Agora Enrollment Forms Packet

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