Enrollment Forms Packet (EFP)

Oklahoma Virtual Charter AcademyEnrollment Processing Center 2300 Corporate Park Drive Suite 200 Herndon, VA 20171

Ph. 866.991.3012Fx. 405.212.4014www.k12.com/OVCA

Please review the information below. Based on your student(s) grade and applicable circumstances, you are required to submit documentation in order to complete this step in the enrollment process. You can fax, scan and email, or mail the required paperwork .

Important Note: Please send copies, do not mail the original documents

Fax (preferred): Scan and Email: Mail: 1-405-212-4014 OVCAfax@k12.com Oklahoma Virtual Charter Academy Enrollment Processing Center 2300 Corporate Park Drive Suite 200 Herndon, VA 20171Required For? Item Description Provided by?

Required for all Students

Oklahoma Transfer Application

Please use the instruction provided to complete this form. All “Open Transfer Applications” must be submitted by June 2nd 2014.

Provided in this packet

Authorization for Use of Electronic Signatures

In order to accept all digitally signed documents, you must submit this form.

Home Language Survey Please complete and sign this form.

Title VII Student Eli-gibility Certification 506 form

This form must be signed and submitted. If it does not apply to your student, only include your student’s name and your signature and write “N/A” on the form. If it is applicable to your student, please complete all sections of the form.

Enrollment Question-naire/McKinney-Vento Act

Please complete and sign this form.

Release of RecordsBy filling out this form, you are giving our school permission to request your student’s official records from their previous school after the approval process. If your child was Homeschooled please indicate it on the form, fill out the top portion and sign it.

Attend an In-Person Orientation Session

It is required for you and your student to attend an In-person Start-Up Success session that provides an introduction to the online learning setting. Parents will attend a policy session to learn about important expectations for success in an online school while students take a reading assessment (Kindergarten-6th grade) and/or math assessment (grades 3-12). As part of the parent session, parents will set an appointment to develop a customized Individualized Learning Plan (ILP) for each student. Report card/transcripts must be submitted before the ILP conference can be conducted. These sessions will start in February.

Provided during Orientation Session

Proof of Age Official Birth Certificate (not the hospital issued certificate)

Provided by you

Proof of Residency Current Utility bill (dated within the past 6 months) OR Tax statement OR Mortgage/Rental Agreement statement showing physical address, not post office box OR Voter Registration.

Proof of Internet Complete Internet Bill.

Immunization Record Current Immunization Record.

Required for all Kin-dergarten, 1st and 3rd Grade Students

Proof of Vision Screening This form is required within 30 days of your student’s approval date.

Required for all Kin-dergartent -9th Grade Students

Report Card The most recent Report Card.

Required for all 10th-12th Grade Students Transcripts

You will need to request a copy of your student’s transcript from your student’s current school, which will allow your student’s academic standing. This is required in order to place all 10th -12th graders.

Required for all Students that have an IEP or other Special Education needs

IEP A copy of your student’s current IEP (Individualized Education Plan). Because the IEP expires yearly, please submit the current IEP.

Evaluation Team Report

The Evaluation Team Report is valid for 3 years. If you do not have a copy of your student’s ETR, please obtain a copy from your student’s current school.

Required for all Students that have a 504 plan

504 Accommodation Plan

A copy of your student’s current 504 Accommodation Plan. Because the 504 expires yearly, please submit the current 504.

Revised December 1, 2013

Parent’s Application for an Open Transfer Beginning School Year 2014-15 Instructions: No later than the first Monday in June 2014, the parent/guardian must submit this application to the Receiving District to apply for the 2014-15 school year. No later than 30 days after receiving an Open Transfer application, the Receiving District must notify the parent/guardian and the Sending District of their decision to approve or deny. Within 10 days of receiving approval notification from the Receiving District, the parent shall notify the Receiving District that they intend to enroll their student in the fall. The Receiving District must complete data entry of Open Transfer applications no later than the first Monday in June which will notify the Sending District by the deadline. [70 O.S. § 8-101, 8-10] [House Bill 2131 effective November 2013] RECEIVING DISTRICT (transfer to) SENDING/RESIDENT DISTRICT (transfer from) County Name County Name District Name District Name School Site Requested School Site

Check here if child is currently Home Schooled.

STUDENT INFORMATION First Name Middle Name Last Name Birth Date Grade Level IEP* Date for 2014-15 (Yes / No) I.E.P. Meeting *An IEP is an Individualized Education Program. If parent answered “yes” that child is currently on an IEP, a representative from both districts must be present for an IEP meeting held to discuss the student’s IEP needs. Applicable IEP records must be submitted from the student’s school to the Receiving District and shall be maintained by both districts in accordance with federal and state laws.

An “IEP Service Agreement” does not constitute a transfer under the Education Open Transfer Act and should not be formalized or processed by use of this form. PARENT/LEGAL GUARDIAN MUST COMPLETE AND SIGN: First and Last Name Email (optional) Street Address City Zip Code Home Phone (Area Code) Alternate Phone (Area Code)

1. Does the parent/legal guardian have another child currently attending this same Receiving District on a previous Open Transfer?

__Yes / No__ If “Yes” enter Sibling Name(s):

2. Is this parent/legal guardian a TEACHER employed by this Receiving District? __Yes / No__

3. Is this parent/legal guardian requesting a district that provides a SPECIALIZED DEAF EDUCATION program? __Yes / No__

4. Is this parent/legal guardian requesting to CANCEL an approved Open Transfer for the student(s) listed? __Yes / No __

An Open Transfer may occur outside of statutory time frame with documentation provided when above questions 1, 2 or 3 are “Yes.”

Pursuant to the provisions of the statutes of the state of Oklahoma, and the rules and regulations of the State Board of Education, appli-cation is hereby made to permit the child listed on this form to transfer from their resident Sending District to the Receiving District as indicated on this form. The parent/guardian applicant verifies by their signature (below) that he/she is the custodial parent or legal guardian of the child/children listed above and hereby acknowledges that if this transfer application is approved, the parent/guardian shall be bound by the Compulsory School Attendance Laws of Oklahoma rules and all regulations of the Receiving District named on this transfer application.

SIGNATURE of Parent/Guardian Date

Receiving District received this form on , 2014. The decision must be within 30 days which is , 2014.

An Open Transfer Application must be completed for each student. (You may use one form for up to two students.)

A “Receiving District (transfer to)”: Enter “Oklahoma” as the County Name, enter “Choctaw-Nicoma Park” as the District Name, and enter “Oklahoma Virtual Charter Academy” as the Site Requested.

B “Sending/Resident District (transfer from)”: Enter your county of residence as the County Name, enter your district of residence as the District Name, and enter the school your student would attend as the School Site.

C If you are currently homeschooling your student, check this box. Otherwise, disregard this section.

D Student Information: Complete First Name, Middle Name, Last Name, Birth Date, and Grade level(s) that all students will be entering in the Fall (up to two students).

E “IEP*: Enter “Yes” for applicable student(s) with an IEP; enter “No” if student(s) do not have an IEP.

Note: An IEP and all necessary records must be submitted to the receiving District if this transfer is for any student with a disability being served through an IEP. Such records shall be maintained by both districts in accordance with federal and state laws.

F “Date for I.E.P. Meeting: A joint district meeting for student(s) with an IEP must be held prior to approval of a transfer and the “Date for I.E.P. Meeting” section will be used by OVCA for scheduling purposes. You do not need to enter information in this section.

G “Parent or Legal Guardian Information”: Enter your First Name, Last Name, Email (optional, but preferred), Street Address, City, Zip, Home Phone, and Alternate Phone numbers with area codes.

H Check “Yes” or “No” for the following questions: 1. Does the parent/legal guardian have another child currently attending the

Receiving District (Choctaw-Nicoma Park) on a previous Open Transfer? (Enter the sibling(s) name(s) if yes.)

2. Is the parent/legal guardian requesting this transfer a TEACHER at the Receiving District?

3. Is the parent/legal guardian requesting this transfer specifically to a Receiving District that provides a SPECIALIZED DEAF EDUCATION program?

4. Is the parent/legal guardian requesting to CANCEL an approved Open Transfer for the student(s) listed?

Print and sign your name as parent/guardian and date the Open Transfer Application.

OKLAHOMAVIRTUAL

ACADEMY

A B

D

EC

Fax to 866.991.3017

OR mail to: Oklahoma Virtual Charter Academy Enrollment Processing 2300 Corporate Drive, Herndon, VA 20171

Applications must be received by noon (CST), 06/02/14.

SAMPLE

Oklahoma

Choctaw-Nicoma Park

Oklahoma Virtual Charter Academy

F

G

H

I

I

Revised December 1, 2013

Parent’s Application for an Open Transfer Beginning School Year 2014-15

Instructions: No later than the first Monday in June 2014, the parent/guardian must submit this application to the Receiving District to apply for the 2014-15 school year. No later than 30 days after receiving an Open Transfer application, the Receiving District must notify the parent/guardian and the Sending District of their decision to approve or deny. Within 10 days of receiving approval

notification from the Receiving District, the parent shall notify the Receiving District that they intend to enroll their student in the fall. The Receiving District must complete data entry of Open Transfer applications no later than the first Monday in June which will notify the Sending District by the deadline. [70 O.S. § 8-101, 8-10] [House Bill 2131 effective November 2013] RECEIVING DISTRICT (transfer to) SENDING/RESIDENT DISTRICT (transfer from) County Name Oklahoma County Name District Name Choctaw/Nicoma Park District Name School Site Requested OVCA School Site

Check here if child is currently Home Schooled.

STUDENT INFORMATION First Name Middle Name Last Name Birth Date Grade Level IEP* Date for 2014-15 (Yes / No) I.E.P. Meeting

*An IEP is an Individualized Education Program. If parent answered “yes” that child is currently on an IEP, a representative from both districts must be present for an IEP meeting held to discuss the student’s IEP needs. Applicable IEP records must be submitted from the student’s school to the Receiving District and shall be maintained by both districts in accordance with federal and state laws.

An “IEP Service Agreement” does not constitute a transfer under the Education Open Transfer Act and should not be formalized or processed by use of this form.

PARENT/LEGAL GUARDIAN MUST COMPLETE AND SIGN:

First and Last Name Email (optional) Street Address City Zip Code Home Phone (Area Code) Alternate Phone (Area Code)

1. Does the parent/legal guardian have another child currently attending this same Receiving District on a previous Open Transfer?

__Yes / No__ If “Yes” enter Sibling Name(s):

2. Is this parent/legal guardian a TEACHER employed by this Receiving District? __Yes / No__

3. Is this parent/legal guardian requesting a district that provides a SPECIALIZED DEAF EDUCATION program? __Yes / No__

4. Is this parent/legal guardian requesting to CANCEL an approved Open Transfer for the student(s) listed? __Yes / No __

An Open Transfer may occur outside of statutory time frame with documentation provided when above questions 1, 2 or 3 are “Yes.”

Pursuant to the provisions of the statutes of the state of Oklahoma, and the rules and regulations of the State Board of Education, appli-cation is hereby made to permit the child listed on this form to transfer from their resident Sending District to the Receiving District as indicated on this form. The parent/guardian applicant verifies by their signature (below) that he/she is the custodial parent or legal guardian of the child/children listed above and hereby acknowledges that if this transfer application is approved, the parent/guardian shall be bound by the Compulsory School Attendance Laws of Oklahoma rules and all regulations of the Receiving District named on this transfer application.

SIGNATURE of Parent/Guardian Date

Receiving District received this form on , 2014. The decision must be within 30 days which is , 2014.

AUTHORIZATION FOR USE OF ELECTRONIC SIGNATURE An electronic signature is recognized as a valid signature under the Uniform Electronic Transactions Act, 12A O.S. § 15-101 et seq. By signing this document, I _______________________________ hereby authorize Oklahoma Virtual Charter Academy, hereinafter “school” to accept all correspondence transmitted by me via electronic mail from the e-mail address submitted herein, as a valid electronic message from me and I agree that until I notify school in writing that my e-mail address is changed, all communications sent out from this address shall be upon my digital signature represented by the following: /s/ _____________________________ shall be acceptable as a replacement for my written signature. Parent/Legal Guardian Signature I understand that I am responsible for notifying the school in the event that my email changes by mailing an updated signed “Authorization for Use of Electronic Signature” form to the school. I will not allow another person to utilize my e-mail signature and I am aware that school assumes no liability for the event or the consequences of another party gaining access to my e-mail account, and electronically impersonating me. I understand that I am not guaranteed confidentiality of information that is transmitted electronically (by e-mail or by FAX), by myself, the school or others. In the event that I request, either by electronic signature or in writing, that confidential information be transmitted, I release school from all liability related to the release of the requested information. School will do its utmost to insure confidentiality of all communication between me and the school. By signing below, I release school from any responsibility or liability for consequences pertaining to this request. __________________________________ ______________________________ Student’s Name Date of Birth __________________________________ ______________________________ Parent or Legal Guardian’s Name Today’s Date __________________________________ ______________________________ Street Address Primary E-Mail Address __________________________________ ______________________________ City State Zip Code Signature By signing this Authorization for Use of Electronic Signature, all other previous submissions of this form received by school is invalid.

20___ - 20___ HOME LANGUAGE SURVEY FOR PRE-K-12 SCHOOL DISTRICTS

FOR SCHOOL USE ONLY

Janet Barresi

State Superintendent of Public Instruction Oklahoma State Department of Education

Name of Student: Student ID #: Gender: Male Female School Site: Grade:

Date of Birth: Place of Birth (City/State/Country): Is the student of Hispanic or Latino culture or origin? Yes No Select one or more of the following races: African American/Black American Indian/Alaskan Native Asian Native Hawaiian or Other Pacific Islander White Parent’s/Guardian’s Name: Parent’s/Guardian’s Address: Parent’s/Guardian’s Telephone Number: ( ) Cell Phone:

1. Is a language other than English used in your home? Yes No If NO, go to numbers 6 and 7. If YES, what is that language? 2. Is that language spoken in the home MORE OFTEN than English? LESS OFTEN than English? 3. What language is spoken by adults in the home? 4. What was the first (1st) language your child learned to speak? 5. What was the date (month and year) your child first enrolled in a school in the United States? 6. Parent/Guardian Signature: 7. Date: THIS FORM MUST BE COMPLETED EVERY YEAR WITH CURRENT TEST DATA FOR STATE ACCREDITATION.

If a language other than English is spoken MORE OFTEN (see question #2), the student automatically qualifies as bilingual on application for accreditation. OR

If a language is spoken LESS OFTEN, student qualifies as bilingual on application for accreditation if he or she meets ONE OF THE FOLLOWING: 1. Scores 35% or below on norm-referenced test (NRT) on the composite reading score. 2. Scores limited knowledge or unsatisfactory on Reading Oklahoma Core Curriculum Tests (OCCTs). 3. Designated Limited English Proficient on an Oklahoma English language proficiency assessment: WIDA ACCESS for English language learners (ELLs)

Test, WIDA Placement Test (including K W-APT, W-APT, and Kindergarten MODEL), or the Oklahoma Pre-K Language Screening Tool.

Documentation of a test result for students who marked LESS OFTEN:

1. NRT Test Date: Name of the NRT: Reading Total Composite Score: 2. Reading OCCT Date: Score on Reading OCC T: Limited Knowledge Unsatisfactory Satisfactory Advanced 3. ACCESS for ELLs Test Date: Score on ACCESS for ELLs: 1 2

WIDA Placement Test (K W-APT, W-APT, or Kindergarten MODEL) Date: Score on K W-APT, W-APT, or MODEL: 1 2

Oklahoma Pre-K Language Screening Tool Date: Score on Pre-K Language Screening Tool:

Note: Have test score documentation available for regional accreditation officer review. 1 Composite Score 2   Literacy Score

Last Name First Name Middle Name

Street City Zip Code

OMB Number: 1810-0021 Expiration Date: 04/30/2013

U.S. DEPARTMENT OF EDUCATION OFFICE OF INDIAN EDUCATION

WASHINGTON, DC 20202 TITLE VII STUDENT ELIGIBILITY CERTIFICATION

Elementary and Secondary Education Act, Title VII, Part A, Subpart 1

Parents: Please return this completed form to your child's school. In order to apply for a formula grant under the Indian Education Program, your child's school must determine the number of Indian children enrolled. Any child who meets the following definition may be counted for this purpose. You are not required to complete or submit this form to the school. However, if you choose not to submit a form, the school cannot count your child for funding under the program. This form will become part of your child's school record and will not need to be completed every year. This form will be maintained at the school and information on the form will not be released without your written approval.

Definition: Indian means any individual who is (1) a member (as defined by the Indian tribe or band) of an Indian tribe or band, including those Indian tribe or bands terminated since 1940, and those recognized by the State in which the tribe or band reside; or (2) a descendent in the first or second degree (parent or grandparent) as described in (1); or (3) considered by the Secretary of the Interior to be an Indian for any purpose; or (4) an Eskimo or Aleut or other Alaska Native; or (5) a member of an organized Indian group that received a grant under the Indian Education Act of 1988 as it was in effect October 19, 1994.

NAME OF CHILD ____________________________________ Date of Birth ___________________

(As shown on school enrollment records)

School Name ___________________________________________ Grade _____________

NAME OF TRIBE, BAND OR GROUP________________________________________________________

Tribe, Band or Group is: (check one) Organized Indian Group Federally Recognized, State Meeting #5 of the

_____ Including Alaska Native _____ Recognized _____ Terminated _____ Definition Above

Name of individual with tribal membership: _____________________________________________

Individual named is (check one): _____ Child _____ Child's Parent _____ Child's Grandparent

Proof of membership, as defined by tribe, band, or group is:

A. Membership or enrollment number (if readily available) _________________________ OR

Other (explain) _____________________________________________

Name and address of organization maintaining membership data for the tribe, band or group:

__________________________________________________________

I verify that the information provided above is accurate:

PARENT'S SIGNATURE _______________________________________ DATE ____________________

Mailing Address _______________________________________________ Telephone _________________

Notice: Public Reporting Burden Notice on Reverse Side

PAPERWORK BURDEN STATEMENT

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1810-0021. The time required to complete this portion of the information collection per type of respondent is estimated to average: 15 minutes per Indian student certification (ED 506) form; including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C. 20202-4651. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: Office of Indian Education, U.S. Department of Education, 400 Maryland Avenue, S.W., LBJ/Room 3E200, Washington, D.C. 20202-6335.

Oklahoma Virtual Charter Academy Enrollment Processing Center 2300 Corporate Park DriveSuite 200Herndon, VA 20171

Ph. 866.991.3012Fx. 866.991.3017www.k12.com/ovca

Student 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:

Check below if applicable: o Student was always previously homeschooled

o Student is enrolling in Kindergarten

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:

Release of Student RecordsPlease 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).

Homeschooled or Never Previously Enrolled in School (Fill out only if applicable)

Prior School Information

Sign and Date below

SCHOOL OFFICIALS ONLY:

Send student records to: Oklahoma Virtual Charter Academy Administration Office P.O. Box 4490 Nicoma Park, OK 73066 Fax: 405.259.8332 Phone: 405.259.9478

Student’s Name: Student’s Home Phone:

10

OVCA: Enrollment Questionnaire/McKinney Vento

This form is intended to address the McKinney-Vento Act. Your answers will help determine residency necessary for enrollment and ensure that certain needs will be met for this student.

Presently, where is the student living? Check one box and complete the remainder of the form.

Section A

� In a shelter_______________ � Temporary with more than one family due to loss of job, loss of housing etc. � In a motel, car, or campsite � In a temporary with more than one family due to loss of job, loss of housing etc. � Alone without parental support (independent living student)

Section B

� Choices in Section A do NOT apply.

Student Name: ____________________________________________ Date of Birth: ________________

School: OVCA Grade: __________ Male � Female �

Present Address: ______________________________________________________________________

City: _____________________________ State: _________ Zip: __________ Phone: ________________

Last school attended: _______________________________ City: ___________________ State: _____

Parent/Guardian Name: ________________________________________________________

Parent/Guardian Signature: ___________________________________ Date: _____________________

______________________________________________________________________________

For School Use Only

Student ID #: ______________

E-63Oklahoma State Department of Education Eligibility Documentation Section, July 2013

APPLICATION FOR FREE AND REDUCED-PRICE SCHOOL MEALS

PART 1. ALL HOUSEHOLD MEMBERS

Names of ALL HouseholdMembers

(First, Middle Initial, Last)

Name of School for EachChild/Or Indicate NA IfPerson Is Not in School

Check If a FosterChild (Legal

Responsibility ofWelfare Agency or

Court)*

*If all children in thehousehold are foster

children, skip to Part 5to sign this form.

Check ifNO

Income(Must bechecked

if noincome)

PART 2. BENEFITS

IF ANY MEMBER OF YOUR HOUSEHOLD RECEIVES SNAP, TANF, OR FDPIR, PROVIDE THE NAMEAND CASE NUMBER FOR THE ONE PERSON WHO RECEIVES BENEFITS AND SKIP TO PART 5. IFNO ONE RECEIVES THESE BENEFITS, SKIP TO PART 3.

NAME: CASE NUMBER:

PART 3. IF ANY CHILD YOU ARE APPLYING FOR IS HOMELESS, MIGRANT, OR A RUNAWAY, CHECKTHE APPROPRIATE BOX AND CALL (YOUR SCHOOL, HOMELESS LIAISON, OR MIGRANT COORDI-NATOR) AT PHONE NUMBER ______________________________. Homeless Migrant Runaway

PART 4. TOTAL HOUSEHOLD GROSS INCOME. You must tell us how much and how often.1. NAME(List only householdmembers with income)

2. GROSS INCOME AND HOW OFTEN IT WAS RECEIVED

Earnings From Work BeforeDeductions

Welfare, Child Support,Alimony

Pensions, Retirement, SocialSecurity, SSI, VA Benefits

All Other Income

(Example) Jane Smith $________/________

$________/________

$________/________

$________/________

$________/________

$________/________

$________/________

$________/________

$________/________

$________/________

$________/________

$________/________

$________/________

$________/________

$________/________

$________/________

$________/________

$________/________

$________/________

$________/________

$________/________

$________/________

$________/________

$________/________

199.99 weekly 149.99 every otherweek

99.99 monthly 50.00 monthly

Date Received: _____________

Grade Birth Date

NOTE TO SFA: A household completing this part does not automatically qualify the child for eligibility. The child must be onthe Homeless, Migrant, Runaway List to qualify for free meal benefits.

E-64 Oklahoma State Department of Education Eligibility Documentation Section, July 2013

Choose one or more (regardless of ethnicity):Asian American Indian or Alaska Native Black or African American

White Native Hawaiian or other Pacific Islander

Part 6: Children’s Ethnic and Racial Identities (Optional)

Choose one ethnicity:Hispanic or Latino

Not Hispanic or Latino

PART 5. SIGNATURE AND LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER (ADULT MUST SIGN)

An adult household member must sign the application. If Part 4 is completed, the adult signing the form alsomust list the last four digits of his or her social security number or mark the “I do not have a social securitynumber” box. (See Privacy Act Statement on the back of the next page.)

I certify (promise) that all information on this application is true and that all income is reported. I understand thatthe school will get federal funds based on the information that I give. I understand that school officials may verify(check) the information. I understand that if I purposely give false information, my children may lose mealbenefits and I may be prosecuted.

Sign Here: Date:

Print Name:

Address: Phone Number:

City: State: Zip Code:

Last four digits of social security number: *** - **- I do not have a social security number.

Your children mayqualify for free or re-duced-price meals ifyour household in-come falls at or belowthe limits of this chart.

185% of Poverty Level

FEDERAL ELIGIBILITY INCOME CHART for School Year ______2014

Household Size

12345678

For each add’lfamily member,

add

Annual

21,25728,69436,13143,56851,00558,44265,87973,316

7,437

Monthly

1,7722,3923,0113,6314,2514,8715,4906,110

620

Twice Per Month

8861,1961,5061,8162,1262,4362,7453,055

310

Every Two Weeks

8181,1041,3901,6761,9622,2482,5342,820

287

Weekly

409552695838981

1,1241,2671,410

144

E-65Oklahoma State Department of Education Eligibility Documentation Section, July 2013

Privacy Act Statement: This explains how we will use the information you give us.

The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give theinformation, but if you do not, we cannot approve your child for free or reduced-price meals. You must include the last four digitsof the social security number of the adult household member who signs the application. The last four digits of the social securitynumber is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP),Temporary Assistance for Needy Families (TANF), or Food Distribution Program on Indian Reservations (FDPIR) case number orother FDPIR identifier for your child or when you indicate that the adult household member signing the application does not havea social security number. We will use your information to determine if your child is eligible for free or reduced-price meals and foradministration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education,health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews,and law enforcement officials to help them look into violations of program rules.

The United States Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants foremployment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable,political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived fromany public assistance program, or protected genetic information in employment or in any program or activity conducted or funded byUSDA. (Not all prohibited bases will apply to all programs and/or employment activities.)

If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination ComplaintForm, found online at <http://www.ascr.usda.gov/complaint_filing_cust.html>, or at any USDA office, or call 866-632-9992 torequest the form. You may also write a letter containing all of the information requested in the form. Send your completedcomplaint form or letter to USDA by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 IndependenceAvenue, SW, Washington, DC 20250-9410, by fax 202-690-7442, or e-mail at <program.intake@usda.gov>.

Individuals who are deaf, hard of hearing, or have speech disabilities may contact USDA through the Federal Relay Service at 800-877-8339 or 800-845-6136 (Spanish).

USDA is an equal opportunity provider and employer.

Other Source Categorical Eligibility:

Head Start Even Start Homeless Migrant Runaway

DO NOT FILL OUT THIS PART. THIS IS FOR SCHOOL USE ONLY.

Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice a Month x 24, Monthly x 12

Income Eligibility:

Total Income: ________ Per: Week Every 2 Weeks Twice a Month Month Year

Household Size: __________

Categorical Eligibility: SNAP/TANF FDPIR

Head Start Even Start Homeless Migrant Runaway Foster Child

Reason: Date Withdrawn:

Determining Official’s Signature: Date:

Confirming Official’s Signature: Date:(For Confirmation Reviews Under Verification)Verifying Official’s Signature: Date:(If stamped signature is used, signature must be registered with the Secretary of State and the SFA must have this onfile.)

Eligibility: Free Reduced Denied

Other Source Categorical Eligibility:

E-66 Oklahoma State Department of Education Eligibility Documentation Section, July 2013

SHARING INFORMATION WITH MEDICAID/SOONERCARE

Dear Parent/Guardian:

If your children get free or reduced-price meals, they MAY also be able to get free or low-cost healthinsurance through Medicaid or SoonerCare. Children with health insurance are more likely to get regularhealth care and are less likely to miss school because of sickness.

Because health insurance is so important to children’s well-being, the law allows us to tell Medicaid andSoonerCare that your children are eligible for free and reduced-price meals unless you tell us not to.Medicaid and SoonerCare only use the information to identify children who may be eligible for their programs.Program officials may contact you to offer to enroll your children. Filling out the Application for Free andReduced-Price Meals does not automatically enroll your children in health insurance.

If you do not want us to share your information with Medicaid or SoonerCare, fill out the form below andsend in. (Sending in this form will not change whether your children get free or reduced-price meals.)

No! I DO NOT want information from my Application for Free and Reduced-Price Mealsshared with Medicaid or SoonerCare.

If you checked No, fill out the form below to ensure that your information is NOT shared for the child(ren)listed below:

Child’s Name: School:

Child’s Name: School:

Child’s Name: School:

Child’s Name: School:

Signature of Parent/Guardian: Date:

Printed Name:

Address:

For more information, you may call your child’s school.