AES Step 2

Online Enrollment Step 2 Document 2012-2013

Technology Use Form Andover eCademy will provide a technology kit to each student enrolled in the virtual school for the 2012-2013 school year. The parent or legal guardian of the enrolled student must accept the technology use responsibilities listed below. To indicate that you understand the technology use responsibilities, please initial each line and provide your signature at the bottom of the page. Term: Students may use an Andover eCademy technology kit during the school year while enrolled in the school. Upon termination of a student’s enrollment, Parent/Guardian and student’s rights expire to possess the technology kit. Andover eCademy also reserves the right to terminate possession if the Parent/Guardian and/or student is believed to have violated any part of the agreement. The Parent/ Guardian shall return the technology kit as instructed within two weeks of notification, in the same condition as delivered. Failure to return the technology kit will result in the Parent/Guardian being liable to Andover eCademy for the full value of the technology kit or for any required repairs, and for attorney fees and related costs in recovering the technology kit. Ownership: The technology kit is sole property of Andover eCademy. At no time will ownership be transferred to the Parent/Guardian or student. The technology kit must reside at the address provided on the student’s enrollment form. Written notice must be provided to Andover eCademy within 30 days if the address changes. Condition: The Parent/Guardian agrees to report a loss or damage that may occur to the technology kit within 24 hours of the occurrence. The Parent/Guardian is solely liable for any loss or damage that occurs to the technology kit. A loss or damage report must be submitted to Andover eCademy within 3 days of the occurrence. Maintenance and Repair: The Parent/Guardian is responsible for requesting maintenance and repair of the technology kit while in his or her possession. Use of Technology Kit: The parent/guardian agrees to the following: The technology kit is to be used for the education of the student while enrolled at Andover eCademy and not for the benefit of any other person or for any other purpose.  Each software application provided shall be subject to, and used in accordance with, the license and/or use agreement that accompanies that software application.  All usage of the technology kit shall be subject to Andover eCademy policies and rules regarding Network/Internet use. (refer to handbook)  The Parent/Guardian is solely responsible for ensuring that the software settings, default configurations, and administrative privileges are maintained at the original specified settings that the technology kit had upon delivery and will be liable for any resulting damage to the technology kit.  The Parent/Guardian is solely responsible for keeping User IDs and passwords confidential to prevent unauthorized usage. Insurance: The Parent/Guardian agrees to maintain at his or her expense adequate insurance to cover damage to the technology kit by fire, theft, flood, explosion, accident or other cause to the full replacement value of the technology kit and agrees that he or she will be financially liable for it regardless of the availability of insurance proceeds.

Name of Parent/Legal Guardian (please print) Signature of Parent/Legal Guardian

____________

Date _____________

2012-2013 Fee Sheet

STUDENT’S NAME

GRADE

All students are required to pay a Technology Fee. An “At-Risk Application” will be available in midJuly for families who qualify for the free/reduced lunch program but do not have a lunch made available to them. Students who qualify for free status will not have to pay the technology fee. Students who qualify for reduced status will have to pay $12.50. The free/reduced status does not apply to the laptop deposit. LAPTOP DEPOSIT: Please check the box that applies to you and enter the fee (if any) on the line below. I will be using a new Andover eCademy Dell Laptop and my laptop deposit is $50.00 * *deposit is refundable when laptop is returned upon withdrawal from the program

I will be using a personal computer and my laptop deposit is $0.

LAPTOP DEPOSIT

$_______________

TECHNOLOGY FEE

$

TOTAL FEES

$_______________

25.00

Enrollment forms and fees may be mailed to our office or returned in person to 1413 N. Main St., Monday-Friday, 8:00 a.m.-4:00 p.m. Parents may pay fees using our online option or by check made payable to “Andover USD 385.” To pay online, go to www.andoverecademy.org, click on the enrollment page and follow the steps. Please make sure to put the student’s name and grade level in the description box.

The following pages apply only to students new to Andover eCademy.

KANSAS CERTIFICATE OF IMMUNIZATIONS (KCI) This record is part of the student's permanent record and shall be transferred from one school to another as defined in Section 72-5209 (d) of the Kansas School Immunization Law (amended 1994.)

Student Name:

Address:

Parent or Guardian Name: Phone: Birthdate (MM/DD/YYYY):

Ethnicity:

Race:

SEX: [ ] MALE [ ] FEMALE

County:

RECORD THE MONTH, DAY, AND YEAR THAT EACH DOSE OF VACCINE WAS RECEIVED

VACCINE DTaP/DT/Td/Tdap

1st

DT DTaP Td Tdap DT DTaP Td Tdap

(Diphtheria, Tetanus, Pertussis) Required for

3rd DT DTaP Td Tdap

4th

5th

DT DTaP Td Tdap DT DTaP Td Tdap

(Hepatitis B) Required for school entry.

Varicella

Hx of Disease: Physician Signature:

(Chickenpox) Required for school entry. 2 doses grades K-3 & 7-8.

One dose grades 4-6 and 9-12 for 2012-2013 school year.

MMR

DT DTaP Td Tdap

7th DT DTaP Td Tdap

If additional doses are added, please initial the dose and sign below:

Required for school entry.

HEP B

6th

State Type

school entry. Single Tdap required for grades 7-10.

Polio

2nd

(Measles, Mumps, and Rubella combined) Required for school entry.

MMR Me/Mu/Ru

Date of Illness:

MMR Me/Mu/Ru

Influenza (Flu) Recommended annually for ages 6mo and older. Not required for school entry.

HIB

(Haemophilus Influenzae Type B) Required < 5 years of age for preschool

or child care operated by a school.

PCV

(Pneumococcal Conjugate) Required < 5 years of age for preschool or

child care operated by a school.

HEP A

(Hepatitis A) Required < 5 years of age for preschool or child care

operated by a school.

MCV4

(Meningococcal) Initial dose recommended at 11-12 years of age and booster

dose recommended after 16 years of age. Not required for school entry.

HPV

(Human Papillomavirus) Recommended for males and females at

11-12 years of age. Not required for school entry.

Rotavirus

Recommended < 8 mo. Not required for school entry.

DOCUMENTATION

LEGAL ALTERNATIVES TO VACCINATION REQUIREMENTS "KSA 72-5209"

KCI MAY ONLY BE SIGNED BY A PHYSICIAN (MD/DO), HEALTH DEPT, OR SCHOOL.

q

I certify I reviewed this student's vaccination record and transcribed it accurate

Agency Name: Authorized Representative:

1. "Annual written statement signed by a licensed physician (Medical Doctor/M.D. or Doctor of Osteopathy/D.O.) stating the physical condition of the child to be such that the tests or inoculations would seriously endanger the life or health of the child." Medical exemption shall be validated annually by physician completion of KCI Form B and attachment to the KCI.

Address: The record presented was

q q

Kansas Immunization Record

Date

2. "Written statement signed by one parent or guardian that the child is an adherent of a religious denomination whose religious teachings are opposed to such tests or inoculations."

Other Immunization Record (Specify)

KANSAS IMMUNIZATION PROGRAM 1000 SW Jackson, Suite 075, Topeka, KS 66612-1274 PHONE 785-296-5591 FAX 785-296-6510 WEB SITE www.kdheks.gov/immunize

I give my consent for information contained on this form to be released to the Kansas Immunization Program for the purpose of assessment and reporting.

Parent/Legal Guardian's Signature

Date

Rev. 03/01/2012

KANSAS IMMUNIZATION REQUIREMENTS: Based on age of child as of September 1 of current school year. As per Kansas Statute 72-5209, all children upon entry to school must be appropriately vaccinated. In each column below, vaccines are required for all ages listed in that column. Ages 0-4 Recommended Schedule

Birth

HEP B

2 Months

DTaP/DT POLIO HEP B HIB PCV ROTAVIRUS

4 Months

DTaP/DT POLIO HIB PCV ROTAVIRUS

Ages 5-6 DTaP: 5 Doses

Ages 7 and Older Tdap/Td: 3 doses if no history of any DTaP doses

a) 4 week minimum interval between first 3 doses; 6 month interval between dose 3 and dose 4. b) 4 doses acceptable if dose 4 given on or after the 4th birthday. c) If dose 4 administered before 4th birthday, 5th dose must be given at 4-6 years of age.

a) b) c) d)

4 week minimum interval between dose 1 and dose 2. 6 month interval between dose 2 and dose 3. One dose must be Tdap in the series. Single dose of Tdap required for incomplete DTaP series if age 7 years or older. e) Tdap required for grades 7-10 regardless of interval of last Td. f) Tdap required for grades 11-12 if more than 10 years since previous DTaP.

POLIO - Grade K-1

a)

4 week minimum interval between first 3 doses; 6 month interval required between dose 3 and dose 4; one dose after 4th birthday b) 3 doses acceptable if 4 weeks between dose 1 and 2; 6 months between dose 2 and 3; one dose after 4th birthday POLIO - IPV/OPV Combination Schedule: 4 Doses required a)

6 Months

12-15 Months

15-18 Months

DTaP/DT POLIO HEP B HIB PCV ROTAVIRUS MMR VAR HIB PCV HEP A DTaP/DT

b)

4 week minimum interval between first 3 doses; 6 month interval required between dose 3 and dose 4; one dose after 4th birthday 3 doses not acceptable with combination schedule

MMR: 2 Doses

a) b)

First dose on or after the 1st birthday. Second dose must be given at least 28 days after first dose. None required if prior varicella disease verified by physician. Two doses are recommended for all children.

HEPATITIS B: 3 Doses Recommendations are based on the ACIP recommended schedule.†

a) b) c)

4 Doses

a) 4 week minimum interval between doses, regardless of age given. 3 Doses

a) 4 week minimum interval between each dose, with 1 dose given on or after the 4th birthday. POLIO - IPV/OPV Combination Schedule: 4 Doses

a) 4 week minimum interval between doses, regardless of age given.

MMR: 2 Doses

First dose on or after the 1st birthday. 4 week minimum interval between doses.

VARICELLA: 2 Doses Grades K-3 for 2012-2013 school year

a) b) c) d)

POLIO - All IPV or OPV Schedule

a) First dose on or after the 1st birthday. b) 4 week minimum interval between doses.

VARICELLA: 2 Doses Grades 7-8 for 2012-2013 school year 1 Dose Grades 4-6 and 9-12 for 2012-2013 school year a) First dose on or after the 1st birthday. b) Second dose must be given at least 28 days after first dose. c) None required if prior varicella disease verified by physician. d) Two doses are recommended for all children.

HEPATITIS B: 3 Doses

4 week minimum interval between dose 1 and dose 2. 8 week minimum interval between dose 2 and dose 3. 16 week minimum interval between dose 1 and dose 3. Dose 3 must be given after 24 weeks of age.

a) b) c) d)

4 week minimum interval between dose 1 and dose 2. 8 week minimum interval between dose 2 and dose 3. 16 week minimum interval between dose 1 and dose 3. Dose 3 must be given after 24 weeks of age.

† - The ACIP Schedules may be accessed at: http://www.cdc.gov/vaccines/recs/schedules Vaccine doses given up to 4 days before the minimum interval or age may be considered valid. With the exception of Hepatitis B vaccine, immunizations given before 6 weeks of age are not considered valid. Half doses or reduced doses of vaccine are not considered valid.

PARENTS AND/OR GUARDIANS ARE NOT AUTHORIZED TO COMPLETE KCI FORMS. KCI FORM B - MEDICAL EXEMPTION is located at http://www.kdheks.gov/immunize/imm_manual_pdf/KCI_formB.pdf BLANK VERSION OF KCI FORM is available at http://www.kdheks.gov/immunize/download/KCI_Form.pdf A ROSTER WITH THE NAMES OF ALL EXEMPT STUDENTS SHOULD BE MAINTAINED. PARENTS OR GUARDIANS OF EXEMPT CHILDREN SHOULD BE INFORMED THAT THEIR CHILDREN SHALL BE EXCLUDED FROM SCHOOL IN THE EVENT OF AN OUTBREAK OR SUSPECTED CASE OF A VACCINE-PREVENTABLE DISEASE.

USD 385 DEPARTMENT OF HEALTH SERVICES ANDOVER, KANSAS IMMUNIZATION STATEMENT Please sign and return with enrollment forms.

Name of Student: _________________________________________ Date of Birth: _____________________________________________ I have been notified that Kansas Law (K.S.A. 72-5208, 72-5209, 725210, 72-5211 and 72-5211a) requires every pupil enrolling in any school for the first time, prior to admission, to present proof from a physician or local health department that the pupil has received such tests and inoculations as are deemed necessary. In USD 385, proof of each inoculation received must be presented prior to admission. Also, mandatory booster inoculations in all required series must be received (within 30 days for students admitted after September 1). If transferring into USD #385, it is the parents obligation to make sure proof of inoculations are received within 30 days. Required inoculations include the following: DTP, DTaP and/or DT/Td OPV or IPV MMR Hepatitis B Varicella

Additions for Early Childhood Hib PCV7 (pneumococcal) Hepatitis A

Parents will be notified of any additional requirements. Parent/Guardian Signature Indicating Receipt of Notice: _______________________________________Date:_________________ Student is transferring from: _____________________________________ Name of School

Date Student Entered USD #385:

City

St.

_______________________________

Name:

Preferred Contact Number: Recommended FRESHMAN Selections Semester 1

Semester 2

Health Opportunities / Physical Education (required for Graduation)

Math (list) ___________________________

English 9 or English 9 Honors (circle)

Earth Space Science or Honors Earth Space Science (circle)

World Geography

Computer Applications (required for Graduation)

Elective (list)__________________________

Math Progression ( 3 credits beyond Pre-Algebra in high school required) 1. Pre-Algebra

4. Algebra 2 or Liberal Arts Math or Business Math

2. Algebra

5. Advanced Math

3. Geometry

Please complete this form by circling or listing your choices where indicated. A four-year planner is included to help in your decisions. If you have questions please call or e-mail school. We will be here all summer to assist you. A complete copy of the Enrollment Guide with graduation requirements, course descriptions and additional electives can be found at www.andoverecademy.org under the "curriculum" tab.

Please mail, fax or email the completed form to: 1413 N. Main St. Andover, KS 67002 Fax: 316-733-4716 email: scaglionel@usd385.org College bound seniors are encouraged to consider college release or dual credit options.

Name:

Preferred Contact Number: Recommended SOPHOMORE Selections Semester 1

Semester 2

Math (list) ___________________________

English 10 or English 10 Honors (circle)

Biology or Honors Biology (circle)

World History or Honors World History (circle)

Elective (list)__________________________

Math Progression ( 3 credits beyond Pre-Algebra in high school required) 1. Pre-Algebra

4. Algebra 2 or Liberal Arts Math or Business Math

2. Algebra

5. Advanced Math

3. Geometry

Please complete this form by circling or listing your choices where indicated. A four-year planner is included to help in your decisions. If you have questions please call or e-mail school. We will be here all summer to assist you. A complete copy of the Enrollment Guide with graduation requirements, course descriptions and additional electives can be found at www.andoverecademy.org under the "curriculum" tab.

Please mail, fax or email the completed form to: 1413 N. Main St. Andover, KS 67002 Fax: 316-733-4716 email: scaglionel@usd385.org College bound seniors are encouraged to consider college release or dual credit options.

Name:

Preferred Contact Number: Recommended JUNIOR Selections Semester 1

Semester 2

Math (list) ___________________________

English 11 or English 11 Honors (circle)

Chemistry or Honors Chemistry (circle)

U.S. History or Honors U.S. History (circle)

Fine Arts (list) ___________________________

Elective (list)__________________________

Math Progression ( 3 credits beyond Pre-Algebra in high school required) 1. Pre-Algebra

4. Algebra 2 or Liberal Arts Math or Business Math

2. Algebra

5. Advanced Math

3. Geometry

Please complete this form by circling or listing your choices where indicated. A four-year planner is included to help in your decisions. If you have questions please call or e-mail school. We will be here all summer to assist you. A complete copy of the Enrollment Guide with graduation requirements, course descriptions and additional electives can be found at www.andoverecademy.org under the "curriculum" tab.

Please mail, fax or email the completed form to: 1413 N. Main St. Andover, KS 67002 Fax: 316-733-4716 email: scaglionel@usd385.org College bound seniors are encouraged to consider college release or dual credit options.

Name:

Preferred Contact Number: Recommended SENIOR Selections Semester 1

Semester 2

Math - optional if 3 credits are earned or elective (list) ___________________________

English 12 or AP English (circle)

Science - optional if 3 credits are earned or elective (list) ___________________________

Government or Honors Government (circle)

Speech (required for Graduation)

Credit Recovery (list)__________________________

Math Progression ( 3 credits beyond Pre-Algebra in high school required) 1. Pre-Algebra

4. Algebra 2 or Liberal Arts Math or Business Math

2. Algebra

5. Advanced Math

3. Geometry

Please complete this form by circling or listing your choices where indicated. A four-year planner is included to help in your decisions. If you have questions please call or e-mail school. We will be here all summer to assist you. A complete copy of the Enrollment Guide with graduation requirements, course descriptions and additional electives can be found at www.andoverecademy.org under the "curriculum" tab.

Please mail, fax or email the completed form to: 1413 N. Main St. Andover, KS 67002 Fax: 316-733-4716 email: scaglionel@usd385.org College bound seniors are encouraged to consider college release or dual credit options.

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