p ap er w o r k fo r 5th - 8th p ar en ts o n l y p r e-bo
TRANSCRIPT
Pre-Boarding Week ChecklistPaperwork for 5th- 8th Parents Only
The following documents can be delivered by August 2nd, 3rd, or 4th from 9am-3pm OR can bebrought Friday, August 6th at our ‘Meet The Teacher’ event. ALL documents must be completed
upon physical delivery.Please note that proof of residency MUST be attached!
This is a checklist of the things you will need to email or bring with you. Please PRINT this checklist tocomplete and bring with your required documents. If you have children in multiple grades, please submiteach student’s paperwork to their assigned grade level classroom.
Student Name:____________________________________________ Grade ________
Parent(s) Name(s):__________________________________________________
T-Shirts: My child’s T-shirt size is: (circle one)
Youth Sizes: XS/2-4 S/6-8 M/10-12 L/14-16Adult Sizes: XS S M L XL
Please complete and turn in the following:STUDENT INFORMATION PACKET: (available on our webpage)❑ School-Parent-Student Compact Form❑ Permissions & Authorizations Form❑ Dismissal Directive Form❑ Annual Medical Alert Form❑ Authorization for the Administration of Medication (if applicable)❑ Free/Reduced Meal Application (if applicable)❑ Home Language Survey (New students only)❑ Chromebook Contract❑ Chromebook Checkout❑ After School Care Form (if applicable to your student)❑ Proof of Residency (current utility bill, mortgage or lease)
Also, please review the following documents found on the John Rex website under theResources tab:❑ Student Handbook❑ School Calendar❑ School Supply list❑ Dress Code
School-Parent-Student Compact
As a school, we will:• Provide a clearly articulated school mission through which the staff shares a commitment to continuous
improvement. We can make a difference and see the results!• Create a climate of high expectations in which the staff demonstrates that all students can attain mastery of
essential skills. We control enough of the variables to assure all students experience success.• Model positive attitudes and possess the influence necessary to shape the attitudes of students.• Be knowledgeable and skillful in research-based high-yield strategies, learning theory, and teaching methods that will
enable students to achieve success. We will differentiate instruction and provide specific interventions as well asopportunities for enrichment.
• Build instructional leaders who share leadership with the staff. Together with teachers, the administrators willadvance teamwork by providing job-embedded opportunities for teachers to collaborate and grow professionally.
• Measure student academic progress frequently. A variety of assessments will be used and the results of the will beused to improve student performance and to improve the instructional program.
• Give all students the opportunity to learn. Learning is the constant—time and support are the variables! Lack ofprevious opportunity will not be interpreted as a lack of ability to learn. We will allocate a significant amount ofclassroom time to instruction in literacy and math.
• Develop a safe, orderly, and caring atmosphere that is free from threat or harm. Our climate will be conducive to learning.• Recognize student accomplishments and provide opportunities for students to develop leadership and citizenship.• Partner with parents so that they will understand and support our school’s mission. Parents will be given the
opportunity to play an important role in helping our school achieve our mission.• Empowered all stakeholders to take the risks necessary for growth when encompassed in a climate of mutual
respect, care, and compassion in which mistakes are seen as opportunities to learn and their ideas and effortsare appreciated. The entire staff will extend the same respect to students that we desire to receive from themand each other.
As a parent, I will:• Support my child’s learning by ensuring that he/she has proper rest, nutrition, and maintains excellent attendance and
punctuality.• Provide transportation to and from school. JRCS does not provide transportation for students; nevertheless, we will
work with families through transportation concerns that may arise on a case-by-case basis.• Abide by the Student Handbook, procedures, and policies of JRCS.• Obtain the required uniform(s) and ensure my child abides by the Uniform Dress Code of JRCS.• Support my child’s learning by reading with him/her 20 minutes each day, set a positive tone for learning at home,
and provide “protected” time for homework completion.• Strive to make positive use of my time with my child (“quality” one-on-one time).• Participate in decisions relating to my child’s education through a mutually respectful relationship with school staff.• Provide a mutually respectful relationship between all parties (students, parents, teachers, and volunteers).• Support my child’s class/school (i.e. helping in class/school, volunteering in my child’s classroom/school,
communicating with my child’s teachers, attending school events when possible, etc.).
As a student, I will:• Respect and obey those in authority.• Proudly follow the behavioral standards expected at our school and abide by the Code of Conduct, school creed,
expectations, procedures, and policies of JRCS.• Ask questions and seek out additional support when I am not sure about a lesson or learning objective.• Make good choices like paying attention in class, staying on task, doing my best, and working hard at my schoolwork.• Be the very best that I can be each and every day.
Parent Signature: ______________________________________________ Date: _________________________
Child’s Name/Signature: _________________________________________ Date: _________________________
John Rex Charter SchoolPermissions & Authorizations
Parents please read & initial each statement below
_______INITIAL: CHARTER SCHOOL I understand that by enrolling my child at JRCS, I am waiving my right to attend thelocal, non-charter public school._______INITIAL: AFFIRMATION OF MISSION STATEMENT I understand and agree to support the mission statement ofJRCS of, “To offer quality educational opportunities to children in the heart of downtown Oklahoma City through an innovativepublic-private partnership.” I also agree to support the Head of School and Faculty in pursuing this mission._______INITIAL: TRANSPORTATION I understand that JRCS does not provide transportation services for students to and/orfrom school. I further understand that it is my responsibility to provide or arrange for transportation for my child to and/or fromschool each day. I will comply with state compulsory attendance laws. JRCS will work through transportation issues and needswith families on a case-by-case basis._______INITIAL: WALKING FIELD TRIPS I hereby grant permission for my child to participate in walking field trips fromJRCS to nearby locations (e.g. Downtown Library, Myriad Gardens, etc.) Teachers will notify parents about regularlyscheduled trips. Teachers will also notify parents of any additional walking trips at least 24 hours in advance._______INITIAL: PHOTOGRAPHS I understand that student photographs may be used in yearbooks, newsletters, websites,and other school-related publications (e.g. PTA publications.) If I do not want my student’s photograph used or released forthese purposes or for news media, I must contact the school office to submit a written request. This form must be completedeach year._______INITIAL: SCHOOL DIRECTORY I understand that the PTA may publish a school directory and share contactinformation with classroom representatives that could include: student name, grade level, classroom teacher, parent/guardiannames, and contact information. If I do not want my name and contact information released for these purposes, I must contactthe school office to submit a written request. This form must be completed each year._______INITIAL: INTERNET USAGE I understand JRCS provides computer network resources via Oklahoma City PublicSchools. The use of electronic resources shall be consistent with the purpose, mission, and goals of JRCES and used only foreducational and professionalpurposes._______INITIAL: COMMITMENT OF INVOLVEMENT I acknowledge and affirm parental involvement in a child’s education isof primary importance. The role of parents/guardians is to reinforce and assist the teacher in academics, as well associal/emotional, learning in the classroom and at home. Parents are encouraged to demonstrate this involvement bybecoming an active member of the JRCS PTA._______INITIAL: PROMPTNESS, ATTENDANCE: I understand that JRCS begins the school day at 7:50 a.m. and dismissesat 3:15 p.m. Attending and being on time every day is very important. I pledge to support promptness/attendance at JRCS.Failure to maintain satisfactory attendance & punctuality in accordance to the JRCS Student Handbook may result inrevocation of the transfer, if applicable, or other disciplinary actions._______INITIAL: UNIFORM DRESS CODE I pledge to support the published uniform dress code. Failure to maintainsatisfactory dress in accordance to the Uniform Policy may result in revocation of the transfer, if applicable, or otherdisciplinary actions._______INITIAL: DISCIPLINE AND ACADEMIC WORK I acknowledge that my child will follow the JRCS Code of Conduct andExpectations as well as Leveled Discipline Plan. In order to have a climate conducive to learning, each child is responsible forhis/her own behavior and learning. Complying with the published rules is mandatory. Failure to do so will result in revocation of thetransfer, if applicable, or other disciplinary actions. Additionally, my child and I are committed to academic work, homework, dailyclass assignments and maintainingcontinual academic growth._______INITIAL: STUDENT HANDBOOK I acknowledge that my child and I understand the JRCS Student Handbook andthat it is available online at the JRCS website. We will read and comply with the policies contained therein. Paper copies willbe made available uponrequest.
Parent Name (please print) Parent Signature
____________________________________ __________________ _________________Student Name Grade Date
JRCS Dismissal Parent Directive: 5th-8thThe information below assists our staff in making sure your child is in the right location for dismissal
procedures. It is our goal that every child is safely dismissed from John Rex School. Your child's teachermust know the directions from you, the parent, in order to carry them out successfully each day. Changing
this information can be confusing to students and teachers. Please remember, all students are onlyreleased to adults with Student Number Match Card.
Child's Name _______________________ Dismissal Number (completed by office): ________
Grade: _______ Teacher: ______________________________
Please indicate by placing an X in the respective column for each day how your child will go home at the end ofthe day and leave this form with your child's teacher.
CarRider
DayCareBus/VanRider
Walker(outside
northdoors)
Authorized Persons for Pick-upPlease list the names of those authorized to pick upyour child on a regular basis.
Monday ● _________________________● _________________________● _________________________● _________________________● _________________________
Tuesday
Wednesday1:45
dismissal
Thursday
Friday
DAYCARE - If your child will be riding a Daycare Bus/Van, please list the following:Daycare Name: _____________________________
Address:___________________________________________________________Phone: ____________________ Contact Person: _________________________
Print Parent Name_________________________ Phone #_________________
Parent Signature____________________________ Date ___________________
ANNUAL MEDICAL ALERTJohn Rex Charter School
STUDENT NAME ________________________________________ DATE OF BIRTH ______________
PARENT/LEGAL GUARDIAN __________________________ SCHOOL YEAR 2021-2022 GRADE _____
A signed copy of this form must be turned in to the office as part of the annual enrollment.
If prescription medication is to be administered at school, it must be in the original prescription container andthe form Authorization for the Administration of Medication must be signed by the prescribing physician andparent/legal guardian.
Please mark one of the following:______ My child does not have any medical conditions.
______ My child does have a medical condition(s). Please check and explain any medical conditions yourchild has that you would like the school and faculty and staff to be informed of
Conditions TreatmentAllergies❑ Hay Fever❑ Reactions to insect bites/stings❑ Medications❑ Foods❑ Other
Asthma
Diabetes
Seizure Disorder Action plan required. See office.
Hearing Problems Action plan required. See office.
Visual Problems (including wearing glasses/contacts)
Other (please explain):
PHYSICAL EDUCATION CLASS:______ My child can participate in P.E. with NO restrictions.______ My child can participate in P.E. with certain restrictions.
If yes, EXPLAIN: _______________________________________________________________________ My child CANNOT participate in P.E. because of medical restrictions. (Physician's note required)
If yes, EXPLAIN: _________________________________________________________________
Parent/Legal Guardian Signature _____________________________________ Date ________________
John Rex Charter SchoolAuthorization for the Administration of Medication
Authorization and Request for the Administration of Medication at school to be used when a physicianorders:
A. Prescription Medication that is to be given for longer than a 10 day period.B. Medication that is to be given only when needed.C. Non-prescription or “over-the-counter” medication.
Student Name __________________________________ Date of Birth __________________Phone Number _______________________ Teacher ____________________ Grade _______School John Rex Charter School Phone 405-587-8100 Fax 405-587-8105Date form received by the school ____________________________
TO BE COMPLETED BY THE PHYSICIAN OR AUTHORIZED PRESCRIBER:1. Reason for medication__________________________________2. Name of medication__________________________________3. Dosage/amount to be given__________________________________4. Specific time to be administered__________________________________5. Duration (week, month, indefinite, etc.)__________________________________6. Anticipated reaction to medication (symptoms, side effects, etc.)
7. Form of medication/treatment:____ Tablet ____ Liquid ____ Inhaler ____ Injection ____ Nebulizer ____Other
8. Special storage requirements: ____None ____Refrigerate
Physician’s Name Physician’s Signature Date
Address Phone Fax********************************************************************************************************************
TO BE COMPLETED BY THE PARENT/GUARDIAN:I hereby request and give my permission for the above named school to administer the medicationprescribed on this form to my child. If the medication is prescribed by a physician, the pharmacylabel must be attached to the medication. If this medication is an “over the counter medication” itmust be brought in the original container/box. I further understand that I will be responsible forpicking up any medication at the end of the school year. Any medication left at school after June 1will be discarded utilizing proper procedure.
Parent/Guardian Signature Date
Student Technology Contract1. I understand that Chromebooks, iPads, and iMacs are property of John Rex Charter School andas such is a privilege that can be revoked at any time.
2. I understand Chromebooks, iPads, and iMacs are electronic tools for learning first and foremost.
3. I understand that Chromebooks, iPads, and iMacs are for my sole purpose as designatedby my signature below.
4. I understand under no circumstances should any device leave the premises of John RexCharter School without consent from the parent/guardian and teacher.
5. I understand that I am not permitted to remove any device from the johnrexschools.orgdomain.
6. I understand that I am not permitted to alter the design of any device (no stickers ormarkings may be removed or added).
7. I understand that any device is school property and if I damage or destroy a device, I am
responsible for those damages.
8. I agree to the JRCS internet usage policy.“The use of electronic resources shall be consistent with the purpose, mission, and goals of JRCS and usedonly for educational and professional purposes.”
I have read and understand all terms of the Chromebook contract. I will adhere to JRCS internetusage policy as well as the above listed agreements.
Student’s Full Name____________________________ Student Signature ____________________________
Date _____________________________I have discussed this contract with my child and will support the school by reinforcing mychild’s correct use of technology in our school.Parent’s Full Name____________________________ Parent Signature ____________________________
Date _____________________________
Chromebook Checkout Form
Student Name__________________________________ Student Grade Level/Teacher____________________
This form must be filled out for any John Rex student who wants to check out a Chromebook. The followingguidelines must be initialed and signed by both the student and their parents.
I understand that I am only to use the Chromebook for school related activities.________(parent initials) ________(student initials)
I understand that my use of the Chromebook, including websites and documents, can be monitored.
________(parent initials) ________(student initials)
I understand that, as a parent, I am responsible for monitoring my child’s usage of the Chromebook and willsupervise my child while he/she is accessing the internet.
________(parent initials) ________(student initials)
I understand that I am financially responsible for any damages that occur to the Chromebook while it is in mypossession.
________(parent initials) ________(student initials)
I understand that failing to return the Chromebook will result in purchasing the Chromebook for $200.
________(parent initials) ________(student initials)
I agree to the above guidelines for the use of a loaned Chromebook owned by John Rex Charter School.
_______________________________________________(Parent Signature)
_______________________________________________(Student Signature)
John Rex Middle School After-Care Program
1. CHILD INFORMATIONFirst & Last Name: _________________________________Address:___________________________________________________________Birthdate: ___________________Grade: _____Allergies ormedications:______________________________________________________________________________________________________________
2. FAMILY INFORMATION: Parent(s) or Guardian(s):Name: __________________________Address:_______________________________________________________Work Phone: ________________ Cell Phone: _________________Email address: ______________________________________
Name __________________________Address_____________________________________________________________Work Phone: ________________ Cell Phone :_________________Email Address: ______________________________________
3. ATTENDANCE: Please mark all sessions that your child willattend.
Days: Mon _____ Tues _____ Wed _____ Thurs _____ Fri _____Occasional Care: ____________________________________________________
4. PERSON(S) AUTHORIZED TO PICK UP MY CHILD (other than parent orguardian): Name: Relationship: Cell Phone Number:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
After-care is from 3:45 until 6 PM Monday, Tuesday, Thursday, Friday, andWednesdays from 2 until 6 PM. The cost of after-care is $15 daily with a maximum
of $50 a week. Students who have not been picked up by 3:45 on Monday,Tuesday, Thursday, Fridays and 2 PM on Wednesdays will be considered after-care
participants.
5. Parent Signature _____________________________ Date ___________________
MIDDLE SCHOOL (5th-8th Grade) SUPPLY LIST
24 - Mechanical pencils1 - Package of markers (Crayola prefered)1 - Package of crayons (Crayola prefered)1 - Package of highlighters1 - Package of colored pencils (Crayola prefered)2 - Packages of notebook paper2 - Package of copy paper2 - Box of tissue1 - Package of pencil cap erasers1 - Pencil eraser1 - 1 ½ inch 3-ring binder1 - Package of dividers (8 tabs)1 - Bottle of hand sanitizer1 - Clorox wipes1 - Pencil box1- Scissors (6-8 in)
Hyperlinks are strictly examples, not recommendations of purchase to this particular store
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soc
ial s
ecur
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umbe
r of t
he a
dult
hous
ehol
d m
embe
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si
gns
the
appl
icat
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The
last
four
dig
its o
f the
soc
ial s
ecur
ity n
umbe
r is
not r
equi
red
whe
n yo
u ap
ply
on
beha
lf of
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ster
chi
ld o
r you
list
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uppl
emen
tal N
utrit
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Pro
gram
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AP
), Te
mpo
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A
ssis
tanc
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dy F
amili
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AN
F) P
rogr
am o
r Foo
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istri
butio
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rogr
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dian
Res
erva
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DP
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ase
num
ber o
r oth
er F
DP
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entifi
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u in
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te th
at th
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ult h
ouse
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embe
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A by
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ecre
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il R
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venu
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cas
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m o
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hold
INST
RUCT
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So
urce
s of
Inco
me
OPT
ION
AL
Chi
ldre
n's
Rac
ial a
nd E
thni
c Id
entit
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t Fo
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Info
rmac
ión
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onta
cto
y fir
ma
de u
n ad
ulto
Nom
bre
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firm
a el
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ular
io
Fi
rma
del a
dulto
Fech
a de
hoy
Dir
ecci
ón (s
i est
á di
spon
ible
)
Apa
rtam
ento
n.º
Ciud
ad
Es
tado
Cód
igo
post
alTe
léfo
no d
uran
te e
l día
y c
orre
o el
ectr
ónic
o (o
pcio
nal)
"Cer
tifico
(pro
met
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ue to
da la
info
rmac
ión
de e
sta
solic
itud
es v
eraz
y q
ue h
e de
clar
ado
todo
s lo
s in
gres
os. E
ntie
ndo
que
esta
info
rmac
ión
se d
a en
rel
ació
n co
n la
rec
epci
ón d
e fo
ndos
fede
rale
s, y
que
las
auto
rida
des
esco
lare
s pu
eden
ver
ifica
r (c
ompr
obar
) la
info
rmac
ión.
Soy
con
scie
nte
de
que
si h
e da
do in
form
ació
n fa
lsa
con
cono
cim
ient
o de
cau
sa, m
is n
iños
pue
den
perd
er la
pre
stac
ión
de a
limen
taci
ón y
se
me
podr
ía p
roce
sar
con
arre
glo
a la
s le
yes
fede
rale
s y
esta
tale
s pe
rtin
ente
s".
PASO
4
PASO
3D
ecla
rar
los
ingr
esos
de
TOD
OS m
iem
bros
de
la v
ivie
nda
(Om
ita e
ste
paso
si s
u re
spue
sta
es "S
í" en
el P
ASO
2)
Últi
mos
cua
tro
dígi
tos
del n
úmer
o de
la S
egur
idad
Soc
ial
(SSN
- So
cial
Sec
urity
Num
ber)
del
sus
tent
o pr
inci
pal
u ot
ro m
iem
bro
adul
to d
e la
viv
iend
a
M
arqu
e si
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tiene
SSN
A. I
ngre
sos
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iño
A v
eces
, los
niñ
os d
e la
viv
iend
a tie
nen
ingr
esos
. Inc
luya
los
ingr
esos
TO
TALE
S ob
teni
dos
por
todo
s lo
s m
iem
bros
de
la v
ivie
nda
enum
erad
os e
n el
PA
SO 1
aqu
í.
Ayud
a pú
blica
/ man
uten
ción
infa
ntil
/ pen
sión
alim
entic
iaPensión/jubilación/
otros
Nom
bres
de
los
mie
mbr
os a
dulto
s de
la v
ivie
nda
(nom
bre
y ap
ellid
o)
Tota
l de
mie
mbr
os d
e la
viv
iend
a (N
iños
y a
dult
os)
XX
XX
X
Ingr
esos
pro
fesio
nale
s
$ $ $ $ $
¿Con
qué
frec
uenc
ia?
$In
gres
os d
el n
iño
Sem
anal
esQu
ince
nale
s Bi
men
sual
es
Men
sual
es
¿Con
qué
frec
uenc
ia?
B. T
odos
los
adul
tos
mie
mbr
os d
e la
viv
iend
a (in
clui
do u
sted
)
En
umer
e a
todo
s lo
s m
iem
bros
de
la v
ivie
nda
que
no a
pare
zcan
en
el P
ASO
1 (i
nclu
ido
uste
d), a
unqu
e no
rec
iban
ingr
esos
. Por
cad
a m
iem
bro
de la
viv
iend
a en
umer
ado,
si r
ecib
en in
gres
os, d
ecla
re e
l ing
reso
tota
l bru
to
(ant
es d
e im
pues
tos)
por
cad
a fu
ente
en
dóla
res
en n
úmer
os e
nter
os (s
in c
enta
vos)
sol
amen
te. S
i no
reci
ben
ingr
esos
de
ning
una
fuen
te, e
scri
ba '0
'. Si
esc
ribe
"0" o
dej
a al
gún
cam
po e
n bl
anco
, est
á ce
rtifi
cand
o (p
rom
etie
ndo)
que
no
hay
ingr
esos
que
dec
lara
r.
$ $ $ $ $
¿Con
qué
frec
uenc
ia?
$ $ $ $ $
Bim
ensu
ales
¿Con
qué
frec
uenc
ia?
PASO
2
¿Alg
ún m
iem
bro
de s
u vi
vien
da (i
nclu
ido
uste
d) p
artic
ipa
actu
alm
ente
en
uno
o m
ás d
e lo
s si
guie
ntes
pro
gram
as d
e ay
uda:
¿SN
AP,
TAN
F o
FDPI
R?
En c
aso
NEG
ATI
VO >
Vay
a al
PA
SO 3
.En
cas
o A
FIR
MA
TIVO
>
Escr
iba
aquí
un
núm
ero
de e
xped
ient
e y
vaya
al P
ASO
4 (N
o re
llene
el P
ASO
3)
Escr
iba
solo
un
núm
ero
de e
xped
ient
e en
est
e es
paci
o.
Núm
ero
de e
xped
ient
e:
PASO
1
Enum
erar
a T
ODOS
los
mie
mbr
os d
e la
viv
iend
a qu
e se
an b
ebés
, niñ
os y
est
udia
ntes
has
ta e
l 12.
º gra
do in
clus
ive
(si s
e re
quie
ren
más
esp
acio
s pa
ra n
ombr
es a
dici
onal
es, a
djun
te o
tra
hoja
de
pape
l)
Nom
bre
del n
iño
A
pelli
do d
el n
iño
Inic
ial d
el
segu
ndo
nom
bre
¿Est
udia
nte?
Sí
No
Niñ
o en
ré
gim
en
de a
cogi
da
Sin
hoga
r,
mig
rant
e,
fuga
do
Marque todo lo que corresponda
Gra
doD
efini
tion
of H
ouse
hold
M
embe
r: “A
nyon
e w
ho is
liv
ing
with
you
and
sha
res
inco
me
and
expe
nses
, eve
n if
not r
elat
ed.”
Child
ren
in F
oste
r ca
re a
nd
child
ren
who
mee
t the
de
finiti
on o
f Hom
eles
s,
Mig
rant
or
Run
away
are
el
igib
le fo
r fr
ee m
eals
. Rea
d H
ow to
App
ly fo
r Fr
ee a
nd
Redu
ced
Pric
e Sc
hool
Mea
ls
for
mor
e in
form
atio
n.
Defi
nici
ón d
e m
iem
bro
de la
vi
vien
da: "
Cual
quie
r pe
rson
a qu
e vi
va c
on u
sted
y
com
part
a in
gres
os y
gas
tos,
au
nque
no
esté
n em
pare
ntad
os".
Los
niño
s en
rég
imen
de
acog
ida
y
los
que
enca
jan
en la
defi
nici
ón
de p
erso
nas
sin
hoga
r,
mig
rant
es o
fug
ados
tie
nen
dere
cho
a re
cibi
r co
mid
as g
ratis
. Le
a Có
mo
solic
itar
com
idas
es
cola
res
grat
is o
a p
reci
o re
duci
do p
ara
obte
ner
más
in
form
ació
n.
¿No
está
seg
uro
de q
ué
ingr
esos
incl
uir
aquí
?
Del
e la
vue
lta a
la p
ágin
a y
cons
ulte
las
lista
s tit
ulad
as
"Fue
ntes
de
ingr
esos
" par
a ob
tene
r m
ás in
form
ació
n.
La li
sta
"Fue
ntes
de
ingr
esos
de
niñ
os" l
e ay
udar
á en
la
secc
ión
Ingr
esos
del
niñ
o.
La li
sta
"Fue
ntes
de
ingr
esos
de
adu
ltos"
le a
yuda
rá e
n la
se
cció
n To
dos
los
mie
mbr
os
adul
tos
de la
viv
iend
a.
Rea
lice
la s
olic
itud
en lí
nea
en
Prot
otip
o de
sol
icitu
d pa
ra fa
mili
as d
e co
mid
as g
ratis
o a
pre
cio
redu
cido
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anal
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ince
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men
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ensu
ales
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sual
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man
ales
Quin
cena
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anal
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ince
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s Bi
men
sual
es
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sual
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Devu
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licitu
d re
llena
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How
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ares
Ric
hard
B. R
usse
ll re
quie
re e
sta
info
rmac
ión
en e
sta
solic
itud.
No
está
obl
igad
o a
dar
esta
info
rmac
ión,
per
o si
no
lo h
ace,
no
pode
mos
aut
oriz
ar q
ue s
us n
iños
rec
iban
com
idas
gra
tis o
a p
reci
o re
duci
do.
Deb
e in
clui
r lo
s úl
timos
cua
tro
dígi
tos
del n
úmer
o de
la S
egur
idad
Soc
ial d
el m
iem
bro
adul
to d
e la
viv
iend
a qu
e fir
ma
la
solic
itud.
No
son
oblig
ator
ios
los
últim
os c
uatr
o dí
gito
s de
l núm
ero
de la
Seg
urid
ad S
ocia
l cua
ndo
real
iza
la s
olic
itud
en
nom
bre
de u
n ni
ño e
n ré
gim
en d
e ac
ogid
a o
si p
ropo
rcio
na u
n nú
mer
o de
exp
edie
nte
de S
uppl
emen
tal N
utri
tion
Ass
ista
nce
Pro
gram
(SN
AP
- P
rogr
ama
de a
sist
enci
a de
nut
rici
ón c
ompl
emen
tari
a), T
empo
rary
Ass
ista
nce
for
Nee
dy F
amili
es (T
AN
F -
Asi
sten
cia
tem
pora
l par
a fa
mili
as n
eces
itada
s) P
rogr
am o
r Fo
od D
istr
ibut
ion
Pro
gram
on
Indi
an R
eser
vatio
ns (F
DP
IR -
P
rogr
ama
de d
istr
ibuc
ión
de a
limen
tos
en r
eser
vas
indi
as) u
otr
o id
entifi
cado
r FD
PIR
de
su n
iño,
o c
uand
o in
dica
que
el
mie
mbr
o ad
ulto
de
la v
ivie
nda
que
firm
a la
sol
icitu
d no
tien
e un
núm
ero
de la
Seg
urid
ad S
ocia
l. U
sare
mos
su
info
rmac
ión
para
det
erm
inar
si s
u ni
ño ti
ene
dere
cho
a re
cibi
r co
mid
as g
ratis
o a
pre
cio
redu
cido
, y la
adm
inis
trac
ión
y ej
ecuc
ión
de
los
prog
ram
as d
e co
mid
a y
desa
yuno
. PO
DEM
OS
com
part
ir e
sta
info
rmac
ión
con
los
prog
ram
as d
e ed
ucac
ión,
sal
ud y
nu
tric
ión
para
ayu
darl
os a
eva
luar
, fina
ncia
r o
dete
rmin
ar la
s pr
esta
cion
es d
e su
s pr
ogra
mas
, aud
itore
s pa
ra r
evis
ar lo
s pr
ogra
mas
, y a
gent
es d
el o
rden
púb
lico
para
ayu
darl
os a
inve
stig
ar v
iola
cion
es d
e la
s no
rmas
del
pro
gram
a.
De
acue
rdo
con
la le
y fe
dera
l de
dere
chos
civ
iles
y lo
s re
glam
ento
s y
polít
icas
de
dere
chos
civ
iles
del D
epar
tam
ento
de
Agr
icul
tura
de
EE. U
U. (
US
DA
- U
.S. D
epar
tmen
t of A
gric
ultu
re),
el U
SD
A, s
us o
rgan
ism
os, o
ficin
as y
em
plea
dos,
y la
s in
stitu
cion
es q
ue p
artic
ipan
o a
dmin
istr
an lo
s pr
ogra
mas
del
US
DA
tien
en p
rohi
bido
dis
crim
inar
por
mot
ivos
de
raza
, col
or,
orig
en é
tnic
o, s
exo,
dis
capa
cida
d, e
dad
o to
mar
rep
resa
lias
o ve
ngan
za p
or a
ctiv
idad
es a
nter
iore
s a
los
dere
chos
civ
iles
en
cual
quie
r pr
ogra
ma
o ac
tivid
ad ll
evad
a a
cabo
o fi
nanc
iado
por
el U
SD
A.
Las
pers
onas
con
dis
capa
cida
d qu
e re
quie
ran
med
ios
alte
rnat
ivos
de
com
unic
ació
n pa
ra in
form
arse
del
pro
gram
a (p
or
ejem
plo,
bra
ille,
letr
a gr
ande
, cin
ta d
e au
dio,
leng
ua a
mer
ican
a de
sig
nos,
etc
.) de
ben
pone
rse
en c
onta
cto
con
el
orga
nism
o (e
stat
al o
loca
l) do
nde
solic
itaro
n su
s pr
esta
cion
es. L
as p
erso
nas
sord
as o
con
pro
blem
as d
e au
dici
ón o
de
ficie
ncia
s en
el h
abla
pue
den
pone
rse
en c
onta
cto
con
el U
SDA
a tr
avés
del
Fed
eral
Rel
ay S
ervi
ce (s
ervi
cio
fede
ral d
e tr
ansm
isio
nes)
en
el (8
00) 8
77-8
339.
Ade
más
, pue
de e
ncon
trar
info
rmac
ión
del p
rogr
ama
en o
tros
idio
mas
ade
más
del
ingl
és.
Para
pre
sent
ar u
na q
ueja
por
dis
crim
inac
ión
cont
ra e
l pro
gram
a, r
elle
ne e
l for
mul
ario
de
quej
as p
or d
iscr
imin
ació
n co
ntra
el
prog
ram
a de
USD
A, (U
SDA
Prog
ram
Dis
crim
inat
ion
Com
plai
nt F
orm
- AD
-302
7) d
ispo
nibl
e en
líne
a en
: ht
tp:/
/ww
w.a
scr.
usda
.gov
/com
plai
nt_fi
ling_
cust
.htm
l, y
en c
ualq
uier
ofic
ina
del U
SDA,
o e
scri
ba u
na c
arta
dir
igid
a al
USD
A co
n to
da la
info
rmac
ión
solic
itada
en
el fo
rmul
ario
. Par
a so
licita
r un
a co
pia
del f
orm
ular
io d
e qu
eja,
llam
e al
(866
) 632
-999
2. E
nvíe
el
form
ular
io r
elle
nado
o c
arta
al U
SDA
por:
cor
reo:
U
.S. D
epar
tmen
t of A
gric
ultu
re
1400
Inde
pend
ence
Ave
nue,
SW
Was
hing
ton,
D.C
. 202
50-9
410
fax:
(2
02) 6
90-7
442;
o
corr
eo e
lect
róni
co:
prog
ram
.inta
ke@
usda
.gov
.
Esta
inst
ituci
ón a
plic
a el
pri
ncip
io d
e ig
uald
ad d
e op
ortu
nida
des.
No
relle
nar
Para
uso
exc
lusi
vo d
el c
oleg
io
Ann
ual I
ncom
e Co
nver
sion
: Wee
kly
x 52
, Eve
ry 2
Wee
ks x
26,
Tw
ice
a M
onth
x 2
4 M
onth
ly x
12
Hou
seho
ld s
ize
Elig
ibili
ty:
Tota
l Inc
ome
Dat
eD
ate
Cate
gori
cal E
ligib
ility
Fuen
tes
de in
gres
osIN
STR
UCC
ION
ES
Iden
tidad
étn
ica
y ra
cial
de
los
niño
sO
PCIO
NA
L
Dat
e
Fuen
tes d
e in
gres
o de
l niñ
oEje
mpl
o(s)
- U
n am
igo
u ot
ro fa
mili
ar d
a re
gula
rmen
te d
iner
o al
niñ
o
- In
gres
os p
rofe
sion
ales
- Se
guri
dad
Soci
al-
Pago
s po
r di
scap
acid
ad-
Ben
efici
os a
l sup
érst
ite
Fuen
te d
e in
gres
os d
e ni
ños
- In
gres
os d
e un
a pe
rson
a aj
ena
a la
viv
iend
a
- U
n ni
ño ti
ene
un tr
abaj
o fij
o a
tiem
po c
ompl
eto
o
- Un
niño
es
cieg
o o
disc
apac
itado
y r
ecib
e pr
esta
cion
es
de la
Seg
urid
ad S
ocia
l - U
no d
e lo
s pa
dres
es
disc
apac
itado
, est
á ju
bila
do o
ha
falle
cido
, y s
u ni
ño r
ecib
e pr
esta
cion
es d
e la
Seg
urid
ad
Soci
al
- In
gres
os d
e cu
alqu
ier
otra
fuen
te-
Un
niño
rec
ibe
ingr
esos
reg
ular
es d
e un
fond
o de
p
ensi
ones
pri
vado
, anu
alid
ad o
fide
icom
iso
Ingr
esos
pro
fesio
nale
sAy
uda
públ
ica /
pens
ión
alim
entic
ia /
man
uten
ción
infa
ntil
- Su
eldo
, sal
ario
, bon
os e
n ef
ectiv
o-
Ingr
esos
net
os c
omo
autó
nom
o (g
ranj
a o
nego
cio)
Si e
stá
en e
l Ejé
rcito
de
Esta
dos
Uni
dos:
-Sue
ldo
bási
co y
bon
os e
n ef
ectiv
o (N
O in
cluy
a el
pag
o de
com
bate
, FS
SA o
sub
sidi
os d
e vi
vien
da
priv
atiz
ados
)-
Subs
idio
s po
r vi
vien
da fu
era
de
la b
ase,
alim
enta
ción
y r
opa
Fuen
te d
e in
gres
os d
e ad
ulto
s
- Pr
esta
ción
por
des
empl
eo-
Inde
mni
zaci
ón la
bora
l-
Ingr
esos
de
segu
rida
d su
plem
enta
rios
(SSI
-
Supp
lem
enta
l Sec
urity
Inco
me)
- A
yuda
eco
nóm
ica
del e
stad
o o
gobi
erno
loca
l-
Pago
s de
pen
sión
alim
entic
ia-
Pago
s de
man
uten
ción
infa
ntil
- Pr
esta
cion
es p
ara
los
vete
rano
s-
Pres
taci
ón p
or h
uelg
a
Pens
ión
/ jub
ilació
n / o
tros
- Se
guri
dad
Soci
al (i
nclu
idas
la
s pr
esta
cion
es d
e ju
bila
ción
de
empl
eado
s fe
rrov
iari
os y
por
ne
umoc
onio
sis)
-
Pens
ione
s pr
ivad
as o
pre
stac
ión
por
disc
apac
idad
- In
gres
os r
egul
ares
de
fidei
com
isos
o b
iene
s in
mue
bles
- A
nual
idad
es-
Ingr
esos
de
inve
rsió
n-
Inte
rese
s ga
nado
s-
Ingr
esos
de
alqu
iler
- Pa
gos
regu
lare
s en
efe
ctiv
o aj
enos
a la
viv
iend
a
Esta
mos
obl
igad
os a
sol
icita
r inf
orm
ació
n so
bre
la ra
za d
e su
s ni
ños
y su
ori
gen
étni
co. E
sta
info
rmac
ión
es im
port
ante
y a
yuda
a g
aran
tizar
que
ser
vim
os c
ompl
etam
ente
a n
uest
ra c
omun
idad
. Re
spon
der a
est
a se
cció
n es
opc
iona
l y s
us n
iños
seg
uirá
n te
nien
do d
erec
ho a
sol
icita
r com
idas
esc
olar
es g
ratis
o a
pre
cio
redu
cido
.
Raz
a (m
arqu
e un
a o
más
):In
dio
amer
ican
o o
nativ
o de
Ala
ska
Asi
átic
o
N
egro
o a
froa
mer
ican
o
Nat
ivo
de H
awái
u o
tra
isla
del
Pac
ífico
Bla
nco
Gru
po é
tnic
o (m
arqu
e un
o):
His
pano
o la
tino
No
hisp
ano
o la
tino
Free
Redu
ced
Deni
ed
Det
erm
inin
g Offi
cial
’s S
igna
ture
Co
nfirm
ing
Offici
al’s
Sig
natu
reVe
rify
ing
Offici
al’s
Sig
natu
re
parc
ial e
n el
que
gan
a un
sue
ldo
o sa
lari
o
(Template)
School Year 2021 - 2022 Economically Disadvantaged Form
This application should be completed even if your student attends a Community Eligibility Provision or Provision School.
School: Grade: Student Number:
Student Name: _____________________________________
Signature: I certify that all information provided on this form is true to the best of my knowledge and that all household income is reported. I understand that this information will impact federal and state funding to the school.
Sign Here: Date: _______________________________
Print Name: _____________________________________________________________________________________
Qualified Not Qualified
Less than $23,828 Between $49,025 and $57,424 Between $82,621 and $91,020
Between $23,828 and $32,227 Between $57,424 and $65,823 Between $91,020 and $99,419
Between $32,227 and $40,626 Between $65,823 and $74,222 Between $99,419 and $107,818
Between $40,626 and $49,025 Between $74,222 and $82,621 Between $107,818 and $116,217
One (1) Five (5) Nine (9)
Two (2) Six (6) Ten (10)
Three (3) Seven (7) Eleven (11)
Four (4) Eight (8) Twelve (12)
Please select the income range that represents the total annual gross income:
Please select the total number of people in your household:
For Office use only:
Basic Uniform Dress CodeJohn Rex Charter School has school uniform dress code requirements for all students.Students are expected to adhere to the basic school dress code. Students found inviolation of the uniform policy will be sent to the office to call a parent or guardianto bring appropriate clothing to school. Students not in compliance with the uniformpolicy are subject to the JRCS Code of Conduct. Students found in repeated violation ofthe dress code are subject to further disciplinary action.
Basic Shirts● Polo-style shirts: School uniform short or long sleeve-solid white, light blue, or navy
polo-style pique or interlock shirts.● Oxford shirts: School uniform dress shirts-short or long sleeve, solid white or oxford blue
with collar.● School T-Shirts: Wednesdays only-students may wear school or PTA purchased t-shirts
instead of the regular school uniform shirt choices. All other school uniform dress code rulesapply to other garments.
● Layered clothing must also meet school uniform required colors (see above).● Shirts may not have visible insignias, logos, labels, words, or pictures except for the
approved school logo.
Basic Pants, Shorts, Skirts & Skorts● Pants/shorts: School uniform khaki or navy twill (chino) fabric (appropriate length).● Skirts/skorts: School uniform khaki or navy twill (chino) fabric (appropriate length).
Basic Dresses/Jumpers● Dresses/jumpers: School uniform khaki or navy twill (chino) fabric (appropriate length).● Polo-style dresses: School uniform pique navy, light blue, or white (appropriate length).
Basic Accessories● Belts must be solid, dark (brown/black) color.● Layered clothing must also meet uniform required colors. See above.● Ties: School uniform solid navy blue or Lands End “Clear Blue Plaid” (this is
the only approved plaid).
Basic Footwear● Shoes: students must wear closed-toe shoes at all times while on school property.
Shoes should be appropriate for playground and gym activity. Students may not wearflip-flops, beach, pool wear shoes, or house shoes (i.e. Crocs).
Other Basic Items● Sweaters & Jackets: Solid navy or white crew sweatshirts, long sleeve v-neck
sweaters, v-neck sweater vests, cardigan sweaters (button or zip), or fleece jackets(zip front), without hoods. These may not have visible insignias, logos, labels, words,or pictures except for the approved school logo.
● Coats/outerwear: student’s choice and are removed once inside the school.● Hair should be well groomed and students should refrain from using coloring
(including gels or sprays) or other hairstyles that could be deemed as a distraction inthe classroom.
Student Signature _________________________________________ Date __________Parent Signature __________________________________________ Date __________
Middle School Arrival/Dismissal Procedures:
Arrival:
● Students may enter the school beginning at 7:15am. Breakfast will be served from 7:15-7:45am.
● Drop off traffic must follow the layout shown in the map above. Please be aware that multiple
businesses use this parking lot. Remember to be courteous to workers from neighboring companies
that may need to cross our drop off line.
● Students will be dropped off in the staff parking lot identified on the map with a YELLOW star.
● Teachers will be located at the YELLOW star daily to greet each student.
● Students will enter the McAlpine Center/Middle School through the north doors.
● Lobby doors will be locked at 7:50am. Parents/Guardians must check-in any student arriving after
7:50am. Any child dropped off after 7:50am without an adult checking them in will remain in the front
office until a parent/guardian returns to check them in.
Dismissal:
● Students will be dismissed through the north doors beginning at 3:15pm on Monday, Tuesday,
Thursday, and Friday and at 1:45 on Wednesday.
● Car riders Pick up traffic must follow the layout shown in the map above. Please be aware that multiple
businesses use this parking lot. Remember to be courteous to workers from neighboring businesses
that may need to cross our pick up line. Once your child is in the car, please continue north on Walker
Ave.
● Walkers Parent/Guardian walking from home/work must inform the adult at the GREEN starwhich student they are picking up and provide the SafeSchool ID number assigned to thatstudent for verification. Students will be called to meet the parent/guardian at the northentrance.
John Rex Charter School Calendar: 2021-22July 2021 August 2021 September 2021 Date Event or Holiday
Su M Tu W Th F Sa Su M Tu W Th F Sa Su M Tu W Th F Sa August 3 Orientation for New Teachers1 2 3 1 2 3 4 5 6 7 1 2 3 4 August 4-6 & 9-10 All Teachers: Professional Development & Work Days
4 5 6 7 8 9 10 8 9 10 11 12 13 14 5 6 7 8 9 10 11 August 11 First day of school for students11 12 13 14 15 16 17 15 16 17 18 19 20 21 12 13 14 15 16 17 18 Sept 6 Labor Day Holiday (school closed)18 19 20 21 22 23 24 22 23 24 25 26 27 28 19 20 21 22 23 24 25 Oct 7 Parent Conference Day (no school for students)25 26 27 28 29 30 31 29 30 31 26 27 28 29 30 Oct 8 Teacher Prof Dev & Work Day (no school for students)
15 21 Oct 11-15 Fall Break (school closed) Nov 22-26 Thanksgiving Break (school closed)
October 2021 November 2021 December 2021 Dec 20-Jan 3 Winter Break (school closed) Su M Tu W Th F Sa Su M Tu W Th F Sa Su M Tu W Th F Sa Jan 3 Teacher Prof Dev & Work Day (no school for students)
1 2 1 2 3 4 5 6 1 2 3 4 Jan 4 Classes resume for students3 4 5 6 7 8 9 7 8 9 10 11 12 13 5 6 7 8 9 10 11 Jan 17 MLK Jr. Day (school closed)
10 11 12 13 14 15 16 14 15 16 17 18 19 20 12 13 14 15 16 17 18 Feb 21 President's Days (school closed)17 18 19 20 21 22 23 21 22 23 24 25 26 27 19 20 21 22 23 24 25 March 10 Parent Conference Day (no school for students)24 25 26 27 28 29 30 28 29 30 26 27 28 29 30 31 March 11 Teacher Prof Dev & Work Day (no school for students)31 14 17 13 March 14-18 Spring Break (school closed)
April 28 & 29 Downtown Arts Festival Days (school closed)January 2022 February 2022 March 2022 May 25 Last day of school for students
Su M Tu W Th F Sa Su M Tu W Th F Sa Su M Tu W Th F Sa May 26 & 27 Teacher Record Day & Work Day (no school for students)1 1 2 3 4 5 1 2 3 4 5 May 30 Memorial Day (offices closed until August)
2 3 4 5 6 7 8 6 7 8 9 10 11 12 6 7 8 9 10 11 12 Holiday (No School)9 10 11 12 13 14 15 13 14 15 16 17 18 19 13 14 15 16 17 18 19 Breaks (No School)
16 17 18 19 20 21 22 20 21 22 23 24 25 26 20 21 22 23 24 25 26 2 Parent Conference Days (no school for students)23 24 25 26 27 28 29 27 28 27 28 29 30 31 10 Teacher Work Day (No School)30 31 19 19 16 1 New Teacher Orientation
171 Total Student Academic Days April 2022 May 2022 June 2022 [42]
Su M Tu W Th F Sa Su M Tu W Th F Sa Su M Tu W Th F Sa
1 2 1 2 3 4 5 6 7 1 2 3 4
3 4 5 6 7 8 9 8 9 10 11 12 13 14 5 6 7 8 9 10 11
10 11 12 13 14 15 16 15 16 17 18 19 20 21 12 13 14 15 16 17 18
17 18 19 20 21 22 23 22 23 24 25 26 27 28 19 20 21 22 23 24 25
24 25 26 27 28 29 30 29 30 31 26 27 28 29 3019 18