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School Form
UHS-Meridell
2023-10-10T13:16:20-04:00
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RESIDENTIAL CAMPUS REGISTRATION FORM
JHW Inspire Academies
Afton Campus, 620 East Afton Oaks, San Antonio, TX 78232, Phone: 210-638-5500, Fax: 210-638-5575
Bell Campus, 4800 E. Rancier Ave., Killeen, TX 76543, Phone: 210-638-5250, Fax: 254-618-4290
Hays Campus, 2250 Clovis Barker Rd., San Antonio, TX 78666, Phone: 210-638-5400, Fax: 210-638-5475
Legacy Ranch, 13326 N. Highway 183, Gonzales, TX 78629, Phone: 210-638-5300, Fax: 210-638-5075
Meridell, 12550 W. Highway 29, Building 9, Liberty Hill, TX 78642, Phone: 210-638-5100, Fax: 512-515-5875
Rockdale Campus, 696 North FM 487, Rockdale, TX 78240, Phone: 210-638-5700, Fax: 210-638-5775
Williams House, 107 E. Railway, Lometa, TX 76853, Phone: 210-638-5800, Fax: 210-638-5075
Student Name
(First, Middle, Last)
Date of Birth
MM slash DD slash YYYY
Gender
Social Security
Enrolling Grade:
1
2
3
4
5
6
7
8
9
10
11
12
Hispanic/Latino (Enter One):
1=Hispanic/Latino, 0=NOT Hispanic/Latino
Federal Ethnicity (Enter One):
I=American Indian/Alaskan Native, A=Asian, B=Black/African American, P=Native-Hawaiian/Pacific Islander, W=White
List educational facilities during the past three years where the student has attended academic classes including summer programs, night school, juvenile justice programs, treatment facilities, etc.
High School Enrollees - list all schools where credit toward graduation may have been awarded:
School Name
District Name
City/State
From Date
To Date
Does the student have a specific food allergy? If yes, which one(s):
YES
NO
Has the student repeated a grade(s)? If so, which one(s)?
YES
NO
Has the student been suspended or assigned to an alternative school?
YES
NO
If yes, when and where?
Has the student been enrolled in any special education, 504, ESL, LEP program?
YES
NO
If yes, which program, when and where:
Which program, when and where:
Which program, when and where:
What was the FIRST year the student was enrolled in Grade 9?
PARENT/GUARDIAN INFORMATION
Note: JHW Inspire Academies does not publish or provide addresses and telephone numbers to any third party. Please provide legal documentation restricting access to your child.
CPS Student
JPD Student
Foster Student
Relationship:
Caseworker
Father/Stepfather
Mother/Stepmother
Guardian
Other
Other:
Name
First
Last
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Work Phone:
Fax Number:
Email
Relationship:
Caseworker
Father/Stepfather
Mother/Stepmother
Guardian
Other
Other:
Name
First
Last
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Work Phone:
Fax Number:
Email
Caseworker/Parent/Guardian Name
Date
MM slash DD slash YYYY
HOME LANGUAGE SURVEY
19 TAC Chapter 89, Subchapter BB 89.1215
JHW Inspire Academies
10325 Bandera Road San Antonio, TX 78250 Telephone: 210-638-5000 Fax: 210-638-5075
Afton
Bell
Hays
Legacy Ranch
Meridell
Rockdale
Williams House
The State of Texas requires that the following information be completed by parent or guardian (or student if Grades 9-12): The State of Texas requires that the following information be completed for each student who enrolls for the first time in a Texas Public School. It is the responsibility of the parent or guardian, not the school, to provide the language information requested by the questions below. This survey shall be kept in each student's permanent record folder.
Debe de completarse por el padre/madre/o representate legal (o por el estudiante si esta en los grados 9-12): El estado de Texas requiere que la sigiuente informacion se complete pasa cada estudiante que se matricula por primera vez en una escuela publica de Texas. Es la responsabilidad del padre o tutor, no de la escuela, proporcianar la informacion del idioma requerida por las siguientes preguntas. Este cucstionario se archivara en el expediente del estudiante.
Student's Name (Nombre del estudiante):
Student's Grade (Grado del estudiante):
Student's ID (ID del estudiante):
Please mark only one language for each question.
What language is spoken in the child's home most of the time?
English
Spanish
Other:
What language does the child speak most of the time?
English
Spanish
Other:
Que idioma se hable en la casa de su hijo(a) la mayoria del tiempo?
Ingles
Espanol
Otra:
Que idioma habla su hijo(a) la mayoria del tiempo?
Ingles
Espanol
Otra:
Signature of Parent/Guardian (firma de padres/guardia)
Signature of Student if Grades 9-12 (firma del estuduante si grados 9-12)
NOTE: If you believe you made an error when completing this Home Language Survey, you may request a correction, in writing, only if: 1) your child has not yet been assessed for English proficiency, and 2) your written correction request is made within two calendar weeks of your child's enrollment date.
NOTA: Si cree que cometio un error al completar este cuestionario sobre el idioma que se habla en el hogar, puede solicitar una correcion, por escrito, solo si: 1) su hijo(a) aun no ha sido evaluado para el dominio dol ingles; y 2) su solicitud de correccion per escrito se realiza dentro do las dos semanas calendario posteriores a la fecha de inscripcion de su hijo(a).
DECISION RECORD OF "AT RISK" STUDENTS
JHW Inspire Academies
Afton Campus, 620 East Afton Oaks, San Antonio, TX 78232, Phone: 210-638-5500, Fax: 210-638-5575
Bell Campus, 4800 E. Rancier Ave., Killeen, TX 76543, Phone: 210-638-5250, Fax: 254-618-4290
Hays Campus, 2250 Clovis Barker Rd., San Antonio, TX 78666, Phone: 210-638-5400, Fax: 210-638-5475
Legacy Ranch, 13326 N. Highway 183, Gonzales, TX 78629, Phone: 210-638-5300, Fax: 210-638-5075
Meridell, 12550 W. Highway 29, Building 9, Liberty Hill, TX 78642, Phone: 210-638-5100, Fax: 512-515-5875
Rockdale Campus, 696 North FM 487, Rockdale, TX 78240, Phone: 210-638-5700, Fax: 210-638-5775
Williams House, 107 E. Railway, Lometa, TX 76853, Phone: 210-638-5800, Fax: 210-638-5075
Student's LEGAL Name
(First, Middle, Last)
Date of Birth
MM slash DD slash YYYY
Pursuant to section 29.081(b) of the Texas Education Code (TEC), school districts in Texas are required to provide accelerated instruction to students who are at risk of dropping out of school. Additionally, school districts are required to evaluate and document the effectiveness of the accelerated instruction in reducing the dropout rate and in increasing achievement of students who are at risk of dropping out of school. HB 7, passed during the 85th Legislative session (2017), modified the criteria for identifying a student as "at risk of dropping out of school" to read as follows:
For purposes of this section, students at risk of dropping out of school includes each student who is under 21 years of age and who:
Was not advanced from one grade level to the next for two or more school years;
Did not maintain, for students enrolled in grades 7-12, an average equivalent to 70 on a scale of 100 in two or more subjects in the foundation curriculum during a semester in the preceding or current school year or is not maintaining such an average in two or more subjects in the foundation curriculum in the current semester;
Did not perform satisfactorily on an assessment instrument administered to the student under Subchapter B, Chapter 39, and who has not in the previous or current school year subsequently performed on that instrument or another appropriate instrument at a level equal to at least 110 percent of the level of satisfactory performance on that instrument;
Is pregnant or is a parent;
Has been placed in an alternative education program in accordance with Section 37.006 during the preceding or current school year;
Has been expelled in accordance with Section 37.007 during the preceding or current school year;
Is currently on parole, probation, deferred prosecution, or other conditional release;
Was previously reported through the Public Education Information Management System (PEIMS) to have dropped out of school;
Is a student of limited English proficiency as defined by Section 29.052;
Is in the custody of the Department of Family and Protective Services or has, during the current school year, been referred to the department by a school official, officer of the juvenile court, or law enforcement official;
Is homeless as defined by 42 USC Section 11302, and its subsequent amendments; or
Resided in the preceding school year or reside in the current school year in a residential placement facility in the district, including a detention facility, substance abuse treatment facility, emergency shelter, psychiatric hospital, halfway house, cottage home operation, specialized child-care home, or general residential operation.
Caseworker/Parent/Guardian Signature
Date
MM slash DD slash YYYY
Comments:
INSPIRE ACADEMIES
P.O. Box 87 Liberty Hill, TX 78642 Phone: 512-528-2150 Fax: 512-515-5875
ATTENTION:
SPECIAL EDUCATION RECORDS AND GENERAL EDUCATION RECORDS
NOTICE FOR RELEASE/CONSENT TO REQUEST CONFIDENTIAL INFORMATION
Student's Name
Date of Birth
MM slash DD slash YYYY
School
Grade
We are asking that you authorize the person or agency named below to release specified records containing confidential information regarding the above-named student to the following school staff person:
Purpose of disclosure:
INFORMATION TO BE RELEASED
TO
FROM
#1 School/Agency, address, phone#, and fax#
#2 School/Agency, address, phone#, and fax#
INFORMATION TO BE RELEASED
TO
FROM
JHW INSPIRE ACADEMY-MERIDELL ATTENTION: Julie Esper-Campus Registrar P.O. Box 87 Liberty Hill, TX 78642 Phone: 512-528-2150 Fax: 512-515-5875 Email:
[email protected]
*Please fax or e-mail IEP/TRANSCRIPT*
RECORDS TO BE RELEASED/RECORDS REQUESTED:
ARD/IEP Reports
Full and Individual Evaluation
Speech/Language Evaluation
State Testing Results
504 Plan
Eligibility Reports
Other: Any other school related information
Transcript/report card/W/D grades
PLEASE CHECK THE APPROPRIATE BOXES BELOW:
The student's current and previous school district are not required to obtain parental consent before requesting or sending the student's special education records if the disclosure is conducted in accordance with 34 CFR 99.31. In Accordance with TEC 25.002, the school district in which the student was previously enrolled shall furnish the new school district with a copy of the student's records, including the child's special education records, not later than the 30th calendar day after the student was enrolled in the new school district (89.1050(f).
I have been fully informed and understand the school's request for my consent as described above. This information will be released/requested upon receipt of my written consent.
Yes
No
I understand that my consent is voluntary and may be revoked at anytime. However, revocation is not retroactive (i.e. it does not negate an action that has occurred after the consent was given and before the consent was revoked).
Yes
No
I understand that I will be notified in writing of each release of educationally related information.
Yes
No
I have been notified in my Native Language.
Yes
No
Signature of Parent/Guardian/Surrogate Parent/Adult Student
Date
MM slash DD slash YYYY
Signature of Interpreter, if used
Date
MM slash DD slash YYYY
School
INSPIRE ACADEMIES
P.O. Box 87 Liberty Hill, TX 78642 Phone: 512-528-2150 Fax: 512-515-5875
NOTICE FOR RELEASE/CONSENT TO REQUEST CONFIDENTIAL INFORMATION
Student's Name
Date of Birth
MM slash DD slash YYYY
Grade
We are asking that you authorize the person or agency named below to release specified records containing confidential information regarding the above-named student to the following school staff person:
Purpose of disclosure:
INFORMATION TO BE RELEASED
TO
FROM
Meridell Achievement Center
INFORMATION TO BE RELEASED
TO
FROM
JHW INSPIRE ACADEMY-MERIDELL ATTENTION: Julie Esper-Campus Registrar P.O. Box 87 Liberty Hill, TX 78642 Phone: 512-528-2150 Fax: 512-515-5875 Email:
[email protected]
Do not add anything, signature only please. *This is authorization for Inspire Academies to share records with Meridell.*
RECORDS TO BE RELEASED/RECORDS REQUESTED:
Incoming Psych/Medical Records
Neuropsychological Assessment
Speech/Language Evaluation
Admission Psychiatric Evaluation
Clinical Formulation
Psychological Evaluation
QEEG Results
Other: Any other school-related information
PLEASE CHECK THE APPROPRIATE BOXES BELOW:
The student's current and previous school district are not required to obtain parental consent before requesting or sending the student's special education records if the disclosure is conducted in accordance with 34 CFR 99.31. In Accordance with TEC 25.002, the school district in which the student was previously enrolled shall furnish the new school district with a copy of the student's records, including the child's special education records, not later than the 30th calendar day after the student was enrolled in the new school district (89.1050(f).
I have been fully informed and understand the school's request for my consent as described above. This information will be released/requested upon receipt of my written consent.
Yes
No
I understand that my consent is voluntary and may be revoked at anytime. However, revocation is not retroactive (i.e. it does not negate an action that has occurred after the consent was given and before the consent was revoked).
Yes
No
I understand that I will be notified in writing of each release of educationally related information.
Yes
No
I have been notified in my Native Language.
Yes
No
Signature of Parent/Guardian/Surrogate Parent/Adult Student
Date
MM slash DD slash YYYY
Signature of Interpreter, if used
Date
MM slash DD slash YYYY
DOCUMENTING HISTORY OF ILLNESS: VARICELLA (CHICKENPOX)
JHW Inspire Academies
Afton Campus, 620 East Afton Oaks, San Antonio, TX 78232, Phone: 210-638-5500, Fax: 210-638-5575
Bell Campus, 4800 E. Rancier Ave., Killeen, TX 76543, Phone: 210-638-5250, Fax: 254-618-4290
Hays Campus, 2250 Clovis Barker Rd., San Antonio, TX 78666, Phone: 210-638-5400, Fax: 210-638-5475
Legacy Ranch, 13326 N. Highway 183, Gonzales, TX 78629, Phone: 210-638-5300, Fax: 210-638-5075
Meridell, 12550 W. Highway 29, Building 9, Liberty Hill, TX 78642, Phone: 210-638-5100, Fax: 512-515-5875
Rockdale Campus, 696 North FM 487, Rockdale, TX 78240, Phone: 210-638-5700, Fax: 210-638-5775
Williams House, 107 E. Railway, Lometa, TX 76853, Phone: 210-638-5800, Fax: 210-638-5075
This form summarizes the "Exceptions to Immunization Requirement (Verification of Immunity/History of Illness)" incorporated in Title 25 Health Services § 97.65 of the Texas Administrative Code (TAC)
§ 97.65 of the TAC states, "A parent or physician validated history of varicella disease (chickenpox) or varicella immunity is acceptable in lieu of vaccine. A written statement from a physician, or the student's parent or guardian, or school nurse must support histories of varicella disease." School nurses may also write this statement to document cases of chickenpox that they observe. The school shall accurately record the existence of any statements attesting to previous varicella illnesses or the results of any serologic tests supplied as proof of immunity, The original should be returned to the child/student or the child's/student's parent or guardian. If a child or student is unable to submit such a statement or serologic evidence, varicella vaccine is required.
This form summarizes the "Exceptions to Immunization Requirement (Verification of Immunity/History of Illness)" incorporated in Title 25 Health Services § 97.65 of the Texas Administrative Code (TAC)
§ 97.65 of the TAC states, "A parent or physician validated history of varicella disease (chickenpox) or varicella immunity is acceptable in lieu of vaccine. A written statement from a physician, or the student's parent or guardian, or school nurse must support histories of varicella disease." School nurses may also write this statement to document cases of chickenpox that they observe. The school shall accurately record the existence of any statements attesting to previous varicella illnesses or the results of any serologic tests supplied as proof of immunity, The original should be returned to the child/student or the child's/student's parent or guardian. If a child or student is unable to submit such a statement or serologic evidence, varicella vaccine is required.
Esta forma resume las "Excepciones al requisito de la immunizacion (Verificacion de la immunidad /historial de la enfermedad)" incorporadas en los Servicios Medicas §97.65 del Titulo 25 del Codigo Administrativo de Tejas (TAC, por sus siglas en ingles).
§ 97.65 del TAC declara, "Un historial de enfermedad de la varicela o immunidad contra la varicela documentado por el medico, o por el padre del nino o estudiante es aceptable en vez de la vacuna. Un informe por escrito de parte del medico, padreo tutor legal del nino o estudiante, o de parte de la enfermera de la escuela debe apoyar historiales de la enfermedad de la varicela." La enfermera de la escuela tambien puede documentar por escrito cualquier caso de varicela que haya ocurrido en la escuela. la escuela debe anotar correctamente la existencio de cuolquier documentacion atestando a cualquier enfermedad de varicela o el resultado de prueba serologica dada como prueba de immunidad. El documento original se debe devolver al nino o estudiante o al padre o tutor legal del nino o estudiante. Si el nino o estudiante no puede someter tal informe o evidencia serologica, la vacuna contra la varicela se requiere.
Documentation of prior varicella illness can be provided by the following methods:
La enfermedad de la varicela debe ser documentada por medio de los siguientes medios de informe:
A serologic confirmation of varicella immunity (positive varicella IgG result).
Prueba seral ogica que confirm immunidad contra la varicela (resultado positivado la prueba de la varicela IgG).
A written statement from a physician, school nurse or the child's/student's parent or guardian containing wording such as that below:
Un informe escrito por elm edico, la enfermera de la escuela o el padre o tutor legal del nino que contiene palabras tales como las siguientes:
This is to verify had varicella disease (chickenpox)
(name of student)
on or about and does not need the varicella vaccine.
(approximate month/day/year)
Esto es para cerificar tuvo la enfermedad
(nombre del estudiante)
de la varicela en por el dia y no recesita la vacuna contra la varicela.
(approximadamente mes/dia/ano)
Signature (firma):
Relationship to student (Parentesco o relaci on al estudiante:
Date (fecha):
MM slash DD slash YYYY
Texas Department of State Health Services, Immunization Branch
Physical Address: 1100 West 49th Street, Austin, Texas 78756 (800) 252-9152 Mailing Address: MC 1946, PO Box 149347, Austin, Texas 78714-9347 (800) 252-9152
The mission of this campus and the JHW Inspire Academies to inspire students to create a life worth living. Our vision is to create premier residential schools that:
The mission of this campus and the JHW Inspire Academies to inspire students to create a life worth living. Our vision is to create premier residential schools that:
Are safe places, physically and emotionally, that develop and nurture students and staff.
Create a culture that inspires students and staff to do their best.
Help students maintain and accelerate their learning through a curriculum that is relevant, challenging, and meaningful.
Individualize and differentiate instruction for all students to challenge them and motivate them to success.
Integrate effective technology as a tool for learning.
Prepare students for life - for healthy relationships for transition to their communities, for on-going education, for career paths.
Help at-risk students fall back in love with learning.
We value:
We value:
Trustworthiness: Our relationships with each other and with our students are built on honesty and trust.
Enjoyment: We enjoy what we do and we have fun.
Accountability: We hold ourselves accountable to the highest standards in all we do.
Compassion: We bring passion to each task and compassion to each person.
Hopefulness: It is never too late - never.
Upon enrollment, each student takes a diagnostic pre-test in reading and mathematics in order to determine educational strengths and weaknesses, and the student receives an individualized course schedule and instructional arrangement based on academic need. Although classrooms are multi-grade, each student will receive appropriate on-grade level instruction in the Texas Essential Knowledge and Skills. The John H. Wood Jr. Public Charter District is fully accredited.
The day at each campus begins with a familiar structure (Pledge of Allegiance, Moment of Silence, school announcements, recognitions, etc.),and each classroom has a structure (greeting, warmup, lesson, practice, closure). Classroom instructions is SACRED: Structured, Accountable, Caring, Relevant, Educational, Dynamic. Teachers create engaging lessons that create positive learning experiences for students in a technology-rich classroom environment that encourages hands-on learning. Students who need additional educational services will receive them.
The campus and district uses C-SCOPE as its curriculum, along with supplemental computerized programs designed to accelerate learning and assist students in the credit recovery process. Students take formative and summative assessments, including unit assessments, benchmark tests and final exams for their courses, and all students participate in state assessments annually.
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