Additional Required DocumentationPart 1: (The pages supplied in this packet)o Release of Student Records

If the student is a home-schooled student, the parent should write “Always Home-schooled” on the form.

o 09-10 OSPI Statement of Understanding

o 09-10 HS WAVA Special Programs Form

o HS Course Enrollment Form ***If applying to enroll in WAVA program affilated with the Omak School District, write in “Omak School District” in the “write in” area, otherwise write in “Monroe School District”.***

o 09-10 Request for Release CHOICE ***If applying to enroll in WAVA program affilated with the Omak School District, write in “Omak School District” in the “write in” area, otherwise write in “Monroe School District”.***

o 09-10 WAVA-HS District Release ***If applying to enroll in WAVA program affilated with the Omak School District, write in “Omak School District” in the “write in” area, otherwise write in “Monroe School District”.***

o 09-10 Intra-Local Attendance Agreement (Must complete if student is sharing attendance with WAVA and the local school district, if applicable make sure to select the correct form.)

o Declaration of Intent to Provide Home-Based Instruction (This form is not necessary if the student is attending WAVA full-time)

o WAVA Immunization Forms (complete the form applicable to your child)

Part 2: (Items you will need to supply)Before you send in your enrollment packet, please be sure you have completed and included copies (do not include originals) of the following:

o Proof of age for each student applying to our program (copy of Birth Certificate)

o Current proof of residency (Copy of utility bill in the form of: water, sewer, gas, garbage, electric, or propane, lease ,or rental agreement)

o A copy of official transcripts (9-12)

o A copy of your student’s Multifactored Evaluation/504 or IEP, if applicable

o District Release Form (This form must be picked up at your local school district office)

Fax or mail the required documents listed in both parts 1 and 2 to WAVA-HS. The fax number for WAVA-HS is 1-253-964-1143.

If you are unable to fax, please mail the documents to:

Washington Virtual Academies

1584 McNeil Street

Suite 200

DuPont, WA 98327

Washington Virtual AcademiesEnrollment Processing Center 1584 McNeil Street, Suite 200DuPont, WA 98327

Ph. 1.866.467.6187Fx. 253.964.1143www.wava.org

SCHOOL OFFICIALS ONLY:

Send student records to: Washington Virtual Academies 1584 McNeil Street, Suite 200 DuPont, WA 98327

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).

Name of Prior School:

School’s Address: street

city county state zip

School’s Phone: ( ) School’s Fax: ( )

Name of Parent or Legal Guardian: first last

Parent/Guardian’s Signature: Date:

Student Information

Prior School 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: ( )

Washington Virtual Academies Enrollment Processing Center 1584 McNeil Street, Suite 200DuPont, WA 98327

Ph. 1.866.467.6187Fx. 253.964.1143www.wava.org

2009-2010 School Year

OSPI STATEMENT OF UNDERSTANDING

In accordance with the Alternative Learning Experience Implementation Standards, reference WAC 392-121-182

(3)(e), prior to enrollment parent(s) or guardian shall be provided with, and sign, documentation attesting to the

understanding of the difference between home-based instruction and enrollment in an alternative learning experience

(ALE).

Provided on this form are descriptions of the difference between home-based instruction and an ALE. Please read

these descriptions and sign below.

Summary Description

Home-Based Instruction

• Is provided by the parent or guardian as authorized under RCW 28A.200 and 28A.225.010.

• Students are not enrolled in public education.

• Students are not subject to the rules and regulations governing public schools, including course, graduation, and

assessment requirements.

• The public school is under no obligation to provide instruction or instructional materials, or otherwise supervise

the student’s education.

Alternative Learning Experience

Washington Virtual Academy (WAVA)

• Is authorized under WAC 392-121-182.

• Students are enrolled in public education either full-time or part-time.

• Students are subject to the rules and regulations governing public school students including course, graduation,

and assessment requirements for all portions of the ALE.

• Learning experiences are:

� Supervised, monitored, assessed, and evaluated by certificated staff.

� Provided via a written student learning plan.

� Provided in whole, or part outside the regular classroom.

Part-time Enrollment of Home-Based Instruction Students

Home-based instruction students may enroll in public school programs, including ALE programs, on a part-time

basis and retain their home-based instruction status. In the case of part-time enrollment in ALE, the student will

need to comply with the requirements of the ALE written student learning plan, but not be required to participate in

state assessments or meet state graduation requirements.

I have read the descriptions of home-based instruction and alternative learning experience provided and I understand

the difference between home-based instruction and the alternative learning experience program in which my child is

enrolling.

Parent Signature_____________________________ Date_____________________

Name(s) of Student(s) ______________________________ ______________________________

______________________________ ______________________________

1584 McNeil Street, Suite 200 DuPont, WA 98327 ph. (253) 964-1068 fx. (253) 964-1143 www.wava.org

Washington Virtual Academies – a program of Steilacoom Historical School District No. 1

To help us better serve your student’s needs and transition, we would like to know about any special services your student has received or is required to receive under state or federal law. This information will not be used to determine enrollment eligibility, but will be used to ensure that your child is provided with proper services.

1. Has your student EVER participated in any of the following special services? (Circle your response) Yes or No

If yes to above � Gifted & Talented � ESL (English as a Second Language) � Title 1/Chapter 1 question, check applicable service(s) � 504 Plan � Special Education/IEP

2. Does your student have an IEP? � Yes � No

3. What is the primary language used in the home regardless of the language spoken by the student? ____________

4. Is a language other than English spoken at home? � Yes � No If so, what language? _______________

5. Does your child speak a language other than English? � Yes � No If so, what language?______________

6. Is there a joint custody plan in effect? �Yes �No If yes, a copy of the plan must be on file with the school for enforcement.

7. Is there a restraining order? �Yes �No If yes, a copy of the plan must be on file with the school for enforcement.

Restraining order is against: �Mother �Father �Other:___________________

Please submit a copy of custody plan and/or restraining order as they pertain to your student. Certification and Signature I certify that all of the above information is true and correct. Signature:______________________________________________ Date:_________________________ Student Name: __________________________________________

Special Programs

Custody Information

Certification and Signature

1584 McNeil St. Suite 200 Phone (253) 964-1068 DuPont, WA 98327 Fax (253) 964-1143

Washington Virtual Academies

09/10 HS Course Enrollment Form

This letter is to provide notice that the parent is exercising the option to have his or her child attend another school district under Washington inter-district choice (RCW 28A.225.220). The following student will attend classes in the (write in)_____________________________________ and participate in courses offered through the Washington Virtual Academies (WAVA) for the 2009/10 school year: Student Information: Student Name: ________________________________ Grade 2009/10: ______ Date of Birth: ___________ Parent/Guardian Name: ___________________________________________________________________

Address/City: _____________________________________________ Zip Code: __________________

Home Telephone: _________________________________ Work Telephone: ________________________ Enrollment Calculation: Please follow these instructions:

1. Complete one form per student 2. List the courses to be taken at WAVA. 3. Add the total numbers of Credits and FTE to be taken 4. Fax signed copy to WAVA office at (253) 964-1143

Course Titles Credits FTE Course Titles Credits FTE

1st Semester Titles 1st Sem 1st Sem 2nd Semester Titles 2nd Sem 2nd Sem

Totals Totals

Home School Status (separate from WAVA) Are you establishing Home School Status? Yes______ No_______

If yes, have you turned in a Letter of Intent to Home School to WAVA? Yes______ No_______

***WAVA is a public school program, for a complete definition refer to the 09-10 OSPI Statement of Understanding*** _____________________________________________________________________________________ Parent Name ________________________________________________________________ _________________ Parent Signature Date

1584 McNeil St. Suite 200 Phone (253) 964-1068 DuPont, WA 98327 Fax (253) 964-1143

09/10 WAVA HS Course Catalog, Grades 9-12 Level 2 Core Level 3 Comprehensive Level 4 Honors and AP English/ Language Arts

• ENG102: Literary Analysis and Composition I

• ENG202: Literary Analysis and Composition II

• ENG302: American Literature

• ENG402: British and World Literature

• ENG103: Literary Analysis and Composition I

• ENG203: Literary Analysis and Composition II

• ENG303: American Literature

• ENG403: British and World Literature

• ENG304: Honors American Literature

• ENG500: AP English Language and Composition

• ENG510: AP English Literature and Composition

Math • MTH102: Math Foundations

• MTH112: Pre-Algebra • MTH122: Algebra I • MTH302: Algebra II • MTH312: Business and

Consumer Math

• MTH113: Pre-Algebra • MTH123: Algebra I • MTH203: Geometry • MTH303: Algebra II • MTH403: Pre-Calculus

and Trigonometry

• MTH124: Honors Algebra I

• MTH304: Honors Algebra II

• MTH500: AP Calculus AB

• MTH510: AP Statistics Science • SCI102: Physical Science

• SCI112: Earth Science • SCI202: Biology • SCI302: Chemistry

• SCI113: Earth Science • SCI203: Biology • SCI303: Chemistry • SCI403: Physics

• SCI304: Honors Chemistry

• SCI510: AP Chemistry • SCI520: AP Physics B

History/ Social Sciences

• HST102: World History • HST212: Geography and

World Cultures (1 sem) • HST302: U.S. History • HST402: U.S.

Government and Politics (1 sem)

• HST412: U.S. and Global Economics (1 sem)

• HST103: World History • HST203: Modern World

Studies • HST213: Geography and

World Cultures (1 sem) • HST303: U.S. History • HST403: U.S.

Government and Politics (1 sem)

• HST413: U.S. and Global Economics (1 sem)

• HST304: Honors U.S. History

• HST500: AP U.S. History• HST510: AP U.S.

Government and Politics (1 sem)

• HST520: AP Macroeconomics (1 sem)

• HST530: AP Microeconomics (1 sem)

• HST540: AP Psychology (1 sem)

1584 McNeil St. Suite 200 Phone (253) 964-1068 DuPont, WA 98327 Fax (253) 964-1143

09/10 WAVA HS Course Catalog, Grades 9-12 (continued) World Languages

• WLG100: Spanish I • WLG200: Spanish II • WLG300: Spanish III • WLG110: French I • WLG210: French II • WLG310: French III • WLG120: German I • WLG220: German II • WLG130: Latin I • WLG230: Latin II • WLG140: Chinese I • WLG240: Chinese II

• WLG500: AP Spanish Language • WLG510: AP French Language

Electives/ Other

• OTH010: Skills for Health (1 sem) • OTH020: Physical Education (1 sem or more) • OTH030: Career Planning (1 sem) • ART010: Fine Art • ART020: Music Appreciation • BUS010: Business Communication and Career

Exploration (1 sem) • BUS020: Business and Personal Relationships (1

sem) • BUS030: Personal Finance (1 sem) • HST010: Anthropology (1 sem) • TCH010: Computer Literacy I (1 sem) • TCH020: Computer Literacy II (1 sem) avail.

Winter 2009 • TCH030: Digital Photography and Graphics (1

sem) • TCH040: Web Design (1 sem) • TCH050: Digital Video Production (1 sem) • TCH060: C++ Programming (1 sem) • TCH070: Game Design I (1 sem) • TCH080: Game Design II (1 sem) • TCH090: 3D Game Creation (1 sem) • TCH016: Flash Animation (1 sem)

1584 McNeil St. Suite 200 Phone (253) 964-1068 DuPont, WA 98327 Fax (253) 964-1143

7

Resident School District ________________________________ 2009/2010 Request for Release—CHOICE One form per student Note: If the FTE of the student will be shared between districts, the CHOICE law does not apply. The sharing of FTE requires an Inter-district Agreement.

New Request Annual Renewal Student Name: ______________________________________Grade 2009/10:_____Date of Birth: Parent/Guardian Name: Address/City: ___________________________________________________________ Zip Code: Home Telephone: ______________________________ Work Telephone: Resident, (Sample) School District: _____________________________________________Currently Enrolled? Y N School District Requested: School/Program Requested: WAVA Please check all that apply: Special Ed 504 Discipline Issues Regular Ed BASIS FOR REQUEST OF RELEASE

A financial, educational, safety, or health condition affecting the student would be reasonably improved as a result of the transfer.

Attendance at the school requested is more accessible to the parent’s place of work or childcare. There is some other special hardship or detrimental condition affecting the student or the student’s immediate family

that would be alleviated as a result of the transfer. PLEASE EXPLAIN. USE BACK OF PAGE, IF NECESSARY: DURATION OF RELEASE: (Optional) THE FOLLOWING CONDITIONS MAY CAUSE THE RELEASE TO BE TERMINATED, AS AUTHORIZED IN SCHOOL DISTRICT BOARD POLICY. (SPECIFY CONDITIONS HERE) Parent/Guardian Signature: ___________________________________________ Date:

CHOICE AGREEMENT Legal Reference: RCW28A.225.220 through 230; WAC 392-1212-182. Under the CHOICE law, the receiving school district effectively becomes the ‘resident’ school district for all matters related to the

education of the student (special education, academic accountability, Core Student Record System, etc).

CERTIFICATION OF RELEASE FROM:

Approved Denied (Name of school district) Student Name: Releasing School District Authorized Signature: Title:

CERTIFICATION OF NON-RESIDENT SCHOOL ACCEPTANCE FROM:

Approved Denied (Name of school district) Non-Resident, accepting School District Authorized Signature:

2009-2010 Request for Release

New Request Annual Renewal Student Name: ___________________________________________Grade 2009/10:_____Date of Birth: ___________ Parent/Guardian Name: ___________________________________________________________________________ Address: ____________________________________________________________City:_______________________ Zip Code: _______________ Home Telephone: ___________________ Work Telephone: ______________________ Resident School District: _____________________________________________________Currently Enrolled? Y N School District Requested: (write in) __________ School/Program Requested: __WAVA___ Please check all that apply: Special Ed 504 Discipline Issues Regular Ed BASIS FOR REQUEST OF RELEASE

A financial, educational, safety or health condition affecting the student would be reasonably improved as a result of the transfer.

Attendance at the school requested is more accessible to the parent’s place of work or childcare. There is some other special hardship or detrimental condition affecting the student or the student’s immediate family

that would be alleviated as a result of the transfer. PLEASE EXPLAIN. USE BACK OF PAGE, IF NECESSARY ________________________________________________________________________________________________________________________________________________________________________________ DURATION OF RELEASE: ___________________________________________________________________________ Parent/Guardian Signature: _______________________________________________________Date:________________

CERTIFICATION OF RELEASE FROM ____________________________________________________________ (Name of school district)

Approved Denied Student Name______________________________________ Releasing School District Authorized Signature______________________________________________________ Date_________________ Title____________________________________________________

CERTIFICATION OF NON-RESIDENT SCHOOL ACCEPTANCE FROM ___

Approved Denied Date: _____________ Washington Virtual Academies Authorized Signature: _______________________________________________________ Title: ______________________________________________________

1584 McNeil St. Suite 200 Phone (253) 964-1068 DuPont, WA 98327 Fax (253) 964-1143

09/10 HS Intra-local Attendance Agreement

Resident School District______________________________ The below named student is enrolled in your district and would like to exercise his/her option to take some courses through WAVA-HS (RCW 28A.225.220). According to WAC 392-121-188, school districts have authority to enter into interdistrict cooperative agreements for instructional services with other school districts under RCW 28A.225.250. Please complete the form below to ensure our districts are reporting the correct FTE. Student Information: Student Name: ____________________________________________ Grade 2009/10: _________ Date of Birth: ______________

Parent/Guardian Name: _____________________________________

Address/City: _____________________________________________ City: ____________________Zip Code: _______________

Home Telephone: __________________________________________ Work Telephone: _________________________________ Enrollment Calculation: Please follow these instructions:

1. Parent & Resident District Official must complete one form per student 2. List the courses to be taken at WAVA and at your local school. 3. Add the total numbers of Credits and FTE to be taken - - FTE cannot exceed 1.0. 4. Have resident school fill out “Resident District Courses”. 5. Fax signed copy to WAVA office at (253) 964-1143 and provide a copy to your resident district

WAVA Course Titles Credit FTE Resident School Course Titles

Credit FTE

Totals

Totals

Total Cumulative Credits and FTE Between WAVA and Resident District Credits FTE

FTE ATTENDANCE AGREEMENT

* Final acceptance into WAVA pending pending approval of (write in) ___________________________________________ _________________________________________________________________________ Parent Name

_________________________________________________________________________ __________________________ Parent Signature Date

* Final acceptance into WAVA pending pending approval of (write in) ___________________________________________ Name of Resident School District: _____________________________________________________________________________

Address: __________________________________________________________________________________________________

City: ________________________________________________ Zip Code: ________________ Phone:: _____________________

_____________________________________________________ ____________________________________________________ Name of District Official Title of District Official

_________________________________________________________________________ __________________________ Signature of District Official Date

WAVA Official __________________________________ _________________________________ _____________ Signature of WAVA Official Title of WAVA Official Date

1584 McNeil St. Suite 200 Phone (253) 964-1068 DuPont, WA 98327 Fax (253) 964-1143

Reviewed by: Date: Staff Signature

Is there an accompanying signed Certificate of Exemption on file? Yes No

DOH 348-013

Rev: 10/15/08

Certificate of Immunization Status (CIS)

Child’s Last Name: First Name: Middle Initial: Child’s Birthdate: Child’s Sex:

Child’s Address:

Parent/Guardian Name:

Parent/Guardian Day Phone:

If completing by hand, write the vaccine in the row to the left of “Dose” and the date the vaccine was received in the “Date” column. Age column is optional. Required for School and Child Care/Preschool Required for Child Care/Preschool Only

Vaccine Dose Date Age Vaccine Dose Date Age Vaccine Dose Date Age Hepatitis B (Hep B) Pneumococcal (PCV, PPV) Hepatitis A (Hep A) 1 1 1 2 2 2 3 3 4 Meningococcal (MCV4, MPSV4) Hepatitis B (Hep B) Alternate schedule for teens 1 1 Polio (IPV, OPV) 2 1 Human Papillomavirus (HPV) Rotavirus 2 1 1 3 2 2 4 3 3 Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT) Influenza (most recent) Other 1 2 3 4 Measles, Mumps, Rubella (MMR) 5 1 2 Diphtheria, Tetanus, Pertussis (Tdap, Td) 1 2 Varicella (chickenpox) Haemophilus influenzae type b (Hib) 1 1 2

I certify that the information provided here is correct and verifiable.

Signature of Parent or Guardian Date 2 Verification of varicella disease history 3 4

Health Care Provider (HCP) Verified

Signed note from HCP attached or HCP provider signature here:

Licensed HCP Signature (MD, DO, ND, PA, ARNP) Date HCP Verified by

Registry

No HCP Sig required if box at left checked.

If school staff find verification in the Registry, then school staff must: See the back of this page for documentation of

immunity, a vaccine trade name reference guide, and a vaccine abbreviation list.

Parental Report ONLY acceptable for some grades. Write date or age child had disease:

Either initial with parent approval or get parent signature below: Staff initials indicating parent approval: ___________________

Parent Signature indicating approval: ___________________

Documentation of Immunity by Blood Test (titer) I certify that the child named on this form has laboratory evidence of immunity to (check all that apply): Diphtheria Hepatitis A Hepatitis B Hib Measles Mumps Polio Rubella Tetanus Varicella Other (list): lab report(s) attached (required) X Typed or Printed Name of Licensed Health Care Provider (MD, DO, ND, PA, ARNP) X Signature of Licensed Health Care Provider (required) Date (required)

Vaccine Trade Names* Read down and across - Trade Names are in Alphabetical Order.

Vaccine Abbreviations* Read down – Abbreviations are in Alphabetical Order.

Trade Name Vaccine Trade Name Vaccine Abbreviations Full Vaccine Name Acel-Imune DTaP Menomune MPSV4 DT Diphtheria, Tetanus ActHIB Hib OmniHIB Hib DTaP Diphtheria, Tetanus, acellular Pertussis Adacel Tdap Pediarix DTaP + IPV + Hep B DTP Diphtheria, Tetanus, Pertussis Boostrix Tdap PedvaxHIB Hib Flu (TIV or LAIV) Influenza Certiva HPV Pentacel DTaP + IPV + Hib HBIG Hepatitis B Immune Globulin Comvax Hib + Hep B Pentavalente DTaP + Hep B + Hib Hep A (HAV) Hepatitis A Daptacel DTaP Pneumovax PPV23 Hep B (HBV) Hepatitis B Decavac Td Prevnar PCV or PCV7 Hib Haemophilus influenzae type b Engerix-B Hep B ProHIBiT Hib HPV Human Papillomavirus Fluarix Flu ProQuad MMRV IPV Inactivated Poliovirus Vaccine FluMist Flu Quadracel DTaP + IPV MCV4 Meningococcal Conjugate Vaccine Fluvirin Flu Recombivax Heb B MPSV4 Meningococcal Polysaccharide Vaccine Fluzone Flu Rotarix Rotavirus MMR Measles, Mumps, Rubella Gardasil HPV RotaTeq Rotavirus MMRV Measles, Mumps, Rubella, Varicella Havrix Hep A Tetramune DTP + Hib OPV Oral Poliovirus vaccine HibTITER Hib TriHIBit DTaP + Hib PCV or PCV7 Pneumococcal Conjugate Vaccine HyperTET TIG Tri-Immunol DTP PPV23 Pneumococcal Polysaccharide Vaccine HyperHEP B HBIG Tripedia DTaP Rota (RV1 or RV5) Rotavirus Ipol IPV Twinrix Hep B + Hep A Td Tetanus, Diphtheria Infanrix DTaP Vaqta Hep A Tdap Tetanus, Diphtheria, acellular Pertussis Kinrix DTaP + IPV Varivax Varicella TIG Tetanus immune globulin Menactra MCV4 VAR or VZV Varicella *These lists may not be comprehensive; visit http://www.doh.wa.gov/cfh/immunize/forms/default.htm for updated lists. DOH 348-013 Revised: 10/15/08

Certificate of Exemption (COE) From School, Child Care and Preschool Immunization Requirements1

DOH 348-106 Revised: 10/15/08 Child’s Last Name: First Name: Middle Initial: Child’s Birthdate: Child’s Sex:

Child’s Address:

Parent/Guardian Name:

Parent/Guardian Day Phone:

Please choose the exemption(s) that apply to your child as listed below.

Temporary Medical Exemption Permanent Medical Exemption

Personal/Philosophical Exemption Religious Exemption

I certify that the child named on this form is medically exempted from the requirement for the following vaccine(s):

Until Vaccine(s) Date (or Perm.)

I do not want my child to get the following vaccine(s). Diphtheria Hepatitis B Hib Measles Mumps Pertussis (whooping cough) Pneumococcal Polio Rubella Tetanus Varicella (chickenpox) Other (indicate):

X Type or Print Name of Licensed Health Care Provider (MD, DO, ND, PA, ARNP)

X Signature of Licensed Health Care Provider Date

Parent/Guardian Notice: “I certify that the information provided here is correct and verifiable. I understand that if there is an outbreak of a vaccine-preventable disease my child has not been fully immunized against (as indicated above, for medical, personal/philosophical or religious reasons), my child may be at risk for disease and can be excluded from school, child care or preschool until the outbreak is over.”

Signature of Parent/Guardian Date

1 RCW 28A.210.080-090 state that before or on the first day of every child’s attendance at any public and private school or licensed day care center in Washington State must present proof of either: (1) full immunization, (2) the initiation of and compliance with a schedule of immunization, as required by rules of the state board of health, or (3) a certificate of exemption, signed by a parent or guardian. Medical exemptions must be signed by a licensed health care provider.