Covenant House Academy Grand Rapids Enrollment Application

Full Name *
Full Name
Preferred Session *
Home Phone Number
Home Phone Number
Personal Phone Number
Personal Phone Number
Gender *
Date of Birth *
Date of Birth
Is the student in a single-family household?
i.e. does more than one immediate family live in the student's home?
Mother's Full Name
Mother's Full Name
Mother's Primary Phone
Mother's Primary Phone
Father's Full Name
Father's Full Name
Father's Primary Phone
Father's Primary Phone
Guardian's Full Name
Guardian's Full Name
Guardian's Primary Phone
Guardian's Primary Phone
Emergency Contact #1
Name
Name
Phone
Phone
Emergency Contact #2
Name
Name
Phone
Phone
Emergency Contact #3
Name
Name
Phone
Phone
Does the student have any allergies, medications, treatments, previous hospital confinements, etc. that the school should be aware of?
Are you currently reporting to a probation or surveilance officer? *
Phone number:
Phone number:
Are you consulting with a case worker? *
Phone number:
Phone number:
Pleas select the student's primary ethnicity.
Consent to Student Services *
I hereby give permission to Covenant House Academy Grand Rapids to release student directory information to any requesting organization deemed appropriate by administration; i.e., Military, Newspapers, Employment Agencies etc. I understand that I have the right to sign an objection form provided by the school office.
Media Release *
I hereby give permission to Covenant House Academy Grand Rapids to use pictures and/or quotes of my student for publication purposes; i.e., district newsletter, website, flyers, etc.
Consent to SMS (text message) Communications *
I hereby give permission to Covenant House Academy Grand Rapids to contact me through my sms service. I understand that these messages will be short and few so as not to use a large amount of data.
Official Request for Records
Please fill out the following form so student records can be transferred from the student’s last school to Covenant House Academy Grand Rapids
Specific Data to be Released
• Health Records • Permanent/Cumulative Records and Behavior Records • Pupil Personnel Services/Special Education Records • All Assessment information, including all state-mandated tests • IEP, MFE • Official Transcripts
Reason for request: *
Confidential Questionaire
Answers to the following questions help better provide our students with the available support they deserve. Please answer all questions below. Answers are confidential.
Have you been attending high school for more than 4 years? *
Are you transferring directly from another school? *
Do you currently have any children or are you expecting a child? *
If so, please request information for on-site daycare through the YMCA]
Has anyone in your immediate family (parents or siblings)… *
Please check all that apply
Have any of the following situations applied to you? *
Please check all that apply.
Do you currently live with a parent? *
Home Language Survey
What is your native language? *
What is the primary language used in your home? *
Were you born in the United States? *
What year did you start school in the United States?
What year did you start school in the United States?
Do you have refugee status?
Section 23a Dropout Recovery Program Student Participant Agreement & Individualized Learning Plan
Students who meet the eligibility requirements in the Section 23a Project Dropout Recovery Program are allowed to take 100% of their coursework through a blended online setting. An advocate will be assigned to each student to facilitate their academic, socio-emotional, and personal growth and development. Any problems or concerns with the coursework or equipment are required to be reported to the advocate as soon as possible. It is the student’s responsibility to complete all assignments, quizzes, and tests or before the due dates set by their online instructor. If the online instructor requests a proctor for specific tests or quizzes, it is the student’s responsibility to make such arrangements with their advocate. The advocate will have access to student progress report. A student’s grade in a course will be determined by the percentage earned in the course, as reported by the online instructor. This percentage will be reported to the advocate, who will assign a final grade for the course. The following criteria must be met in order to participate in the Michigan Department of Education’s Section 23a Dropout Recovery Program (MCL388.1623A): ❖ One direct contact with student’s advocate each week ❖ The creation of an Individualized Learning Plan (ILP) ❖ Ten hours of verifiable on-line coursework or a combination of logged on hours and/or physical attendance as specified in the student’s Individualized Learning Plan (ILP) Failure to meet the Section 23a Dropout Recovery compliance requirements for two consecutive months will result in the student’s disenrollment in the program. The student agrees to abide by all policies, rules and guidelines associated with the program. Any questions or concerns will be directed to the advocate.
I acknowledge that I have read and understand the above requirements.
What is your main postsecondary plan? *
Family Educational Rights and Privacy Act (FERPA) Request to Withhold Directory Information *
FERPA allows the release of certain pieces of “directory information” without the prior written consent of a student’s parent/guardian. The parent/guardian (or student if over 18 years of age) has the legal right to “opt out” of the directory so that no information is released to anyone at any time unless written consent is granted. Directory information includes, but is not limited to, the student’s name; address; telephone listing; date and place of birth; major field of study; grade level; enrollment status; dates of attendance; participation in officially recognized activities and sports; weights and height of members of athletic teams; dates of attendance; degrees and awards received; and the most recent educational agency or institution attended. From time to time, the GVSU Charter Schools Office (CSO) may publish charter school student directory information in the following ways: • Photo or video of student in a newsletter, publication, or social media post (a separate media release will be obtained if student is photographed) • Name, school, and grade in a GVSU CSO newsletter, publication, or social media post (both GVSU CSO original pieces and re-printed stories sent to us by GVSU authorized charter schools)
CHAGR Student Computer Contract
The following policies have been put in place to regulate the use of technology at Covenant House Academy Grand Rapids (CHAGR). These policies have been designed to keep our computers and network running as efficient and problem free as possible. To access CHAGR’s computers, network, and software, please read and sign your agreement to the policies below: 1. Computers, software, network, and internet access should only be used for educational use, as directed by CHAGR staff 2. Social network sites (Facebook, Instagram, Twitter, etc.), Internet game sites, YouTube, online music sites, chat, instant messengers, blogs, non-school email, fantasy sports, gambling sites, etc. are NOT permitted 3. Attempting to or bypassing LanSchool or the school’s firewall by installing software, apps, browser extensions, incognito windows, supervised users, or any other intentional means to get around blocks or to access non-school sites can result in the loss of privileges and disciplinary action 4. Students may be subjected to the loss of computer privileges or disciplinary action for: a. Installing or uninstalling software on the computers b. Moving equipment or cables including keyboards and mice c. Changing their desktop image d. Adjusting windows settings (screensaver, fonts, icon sizes, etc.) e. Engaging in hacking activities or using the network in any way other than its intended educational use f. Altering computer system files, folders, and/or settings g. Sharing their logins or passwords with others h. Behavior which threatens the physical safety of the equipment 5. Accessing the files or class work of other students at CHAGR will be treated as academic dishonesty and can result in the loss of class progress, privileges, and disciplinary action for both parties 6. Students are responsible for their workstations and as such should check their workstations each day when they arrive and inform their teachers of any issues. Students are expected to clean and leave their workstations at the end of the day neat and free of papers or trash.
I understand that access to the network and the use of the computer and is a privilege, not a right. Furthermore, I understand that these policies and procedures must be adhered to and any violations can result in the loss of privileges and disciplinary action. *
Parent Responsibilities *
We, as parents, will support our children’s learning in the following ways: (Please review and check all)
Student Responsibilities *
We, as students, will share the responsibility to improve our academic achievement and achieve the state’s high standards. Specifically, we will: (Please review and check all)
*