2020-21 Pivot Charter School – Enrollment

2020-2021 Program Checklist

Thank you for your interest in Pivot Charter School! To ensure that you provide us with all of the information we need to begin processing your student registration, we ask that you refer to this list of required documents. To be submitted before enrollment at Pivot Charter School:

All pages of this enrollment form are complete

Birth Certificate

Proof of Residency-- Utility Bill, Rental/Mortgage Agreement, or Other Proof of Residency

Copy of expulsion paperwork – if applicable

Proof of guardianship (Caregiver Affidavit or other legal document), if you are not the legal parent or guardian

To be submitted upon enrollment at Pivot Charter School:

Immunization Records

Transcript with year-end grades, progress report, or report card, withdrawal grades

Copy of IEP or 504 – if applicable

Copy of any legal custody documents – if applicable

I certify that all of the required paperwork is included and all statements and information provided are true and correct to the best of my knowledge. Parent Signature: _________________________________________________ Date: _______________________

If you have any questions about the enrollment requirements, please contact:

Anna Toso Admissions Coordinator

2999 Cleveland Avenue, Suite D

Santa Rosa, CA 95403

Phone: 707.843.4676

Email: atoso@pivotcharter.org

2020-21 Pivot Charter School – Enrollment

Enrollment Survey Please fill out a short survey on why you are choosing Pivot Charter School

Pivot’s Program Academic Support Emotional Support

Pivot’s flexible school schedule

More Advanced Placement options

Need to be more challenged

Pivot’s diverse course offerings

Opportunity for virtual schooling

Was not passing my courses

Need more academic help/support from teachers

Individualized educational path

Remediation support

Bullying at previous school

Experience anxiety or depression

Need more emotional help/support from teachers

Other: ______________________________________________

High School Academy (Grades 9-12 only)Please indicate your choice of Pivot Charter School Academy:

UPREP Academy University Preparatory Academy requirements are aligned to Cal State Universities and the University of California A-G minimum requirements for acceptance. Graduating from the UPREP Academy does not guarantee acceptance into any UC or CSU school. The student who graduates from the UPREP academy will have met the minimum acceptance criteria. Students are encouraged to take classes above the minimum requirements for entry into the University of California or Cal State schools and are also encouraged to take Advanced Placement courses.

I would like to enroll in UPREP Academy

Liberal Arts Academy Liberal Arts Academy requirements are NOT aligned to Cal State Universities and the University of California requirements for admissions. Students who graduate from the Liberal Arts Academy will still be eligible to attend many other four and two year colleges and Universities in California and throughout the country. The primary differentiation from the University Preparatory Academy is that since the focus is not on completing the University of California A-G course requirements, students have more flexibility of which courses will meet their high school diploma requirements.

I would like to enroll in Liberal Arts Academy

Student Signature: __________________________________________________________ Date: _____________________________

Parent Signature: ___________________________________________________________ Date: _____________________________

Student Group SurveySome students may qualify for reduced graduation requirements. By taking the time to fill out the survey below, you can help us provide the appropriate resources necessary to serve our students.

□ Student is enrolling directly from a juvenile hall program

□ Student is a migrant farm worker or has a parent/guardian that is a migrant farm worker

□ Student is attending school for the first time in the United States

□ Student has or had a parent in the military

2020-21 Pivot Charter School – Enrollment

Media Release

I grant full rights to use the images resulting from the photography/video filming, and any reproductions or adaptations of the images for fundraising, publicity or other purposes to help achieve the group's aims. This might include (but is not limited to), the right to use them in their printed and online publicity, social media, press releases and funding applications.

□ Yes □ No

Student Discipline Is your child pending expulsion or has your child been expelled in the past year? * If yes, a copy of the expulsion paperwork must be included with your enrollment paperwork □ Yes □ No

Important Reminders for the Pivot Charter School Program

The amount of schoolwork a student completes is how attendance and truancy are determined. At Pivot Charter

School, we have determined that adequate progress and attendance is the completion of at least 5 graded assignments a day for high school students, or 3 graded assignments a day for K-8 students, with a passing grade.

If students are unable to make satisfactory progress in their coursework and/or are placed on the school’s Multi-

Tiered System of Support (MTSS), then they will lose the privilege to be a “virtual” student who works solely from home and must attend the site based program. Attending the site based program ensures that students receive the support they need in order to be successful.

Do not disenroll from your prior school until you are enrolled at Pivot Charter School. If you have any questions

about your current enrollment status, please speak with the Site Coordinator. All students will take either the i-Ready or Exact Path diagnostic assessments upon enrollment. Students’ classes

will not be open until these assessments are complete. Having a reliable computer and consistent Internet connection are crucial to student success. Additionally, make

sure that student and parent/guardian have a valid email address and check it often. Pivot will send out most correspondence and important school information via email.

Date Received by Staff: _____________________________________ Adapted from cms.k12.nc.us

Medication Authorization for Pivot Charter School Students

School Name _______________________________Phone #:_________________________ Fax #:_______________________

To the parent or guardian of __________________________________________________ Birthdate______________________

In order to help protect your child’s health, your consent and written authorization from a licensed healthcare provider are required when it is

necessary for your child to take either prescription or non-prescription medications at the Pivot Charter School Campuses. No medication assistance

will be given to your child at school until this authorization has been received. A separate form is required for each medication. New authorization

forms are required every year at the beginning of school, whenever the dose or directions change, or when a new medication is prescribed. It is your

responsibility to provide all medications to be given at school. Each medication must be in an appropriately labeled original container from the

pharmacy or healthcare provider’s office. Most pharmacies will provide an extra container for school use upon request. Administration of non-

prescription medications at school is discouraged.

PARENT/GUARDIAN’S PERMISSION: I give permission for my child to take the medication described below during school hours. I

understand that it is my responsibility to purchase and supply this medication, and that the staff member assisting my child may not be a licensed

healthcare provider. On behalf of my child, I absolve the Pivot Charter School Board of Education and their agents and employees from any and all

liability whatsoever that may result from my child taking this medication at school. I authorize Pivot Charter School to communicate with the

Authorized Healthcare Provider when necessary.

Signature of parent or guardian Date Contact number

FOR LICENSED HEALTHCARE PROVIDER USE ONLY: (Please write legibly using lay terms)

Medication prescribed: ______________________________Strength/dose/method: _____________________________

Purpose of medication: ___________________________________________________________________________________________________

Relationship to meals, if applicable: _________________________________________________________________________________________

How often and at what time (hour): __________________________________________________________________________________________

When to discontinue medication: ___________________________________________________________________________________________

Specify side effects or adverse reactions: ____________________________________________________________________________________

Other instructions (including emergency situations):_____________________________________________________________________________

Please check all appropriate items. If the first item is checked, Authorization For Self-Medication By Pivot Students must be completed.

❏ Please allow this student to self-administer this medication while during school hours

OR ❏ This student needs supervision/assistance taking this medication (NOT AUTHORIZED TO SELF-CARRY/ADMINISTER) ❏ This medication is to be used for emergencies only

It is necessary for this student to receive this medication during school hours in order to maintain or improve health and to benefit from school

attendance. Please notify the site administrator and parents/guardians if there are any problems.

Signature of Healthcare Provider Date Telephone Fax

Please print Provider’s last name Practice name Address

Adapted from cms.k12.nc.us

AUTHORIZATION FOR SELF-MEDICATION BY PIVOT STUDENTS

Student's Name:_______________________________________ Birthdate:_______________________

Medication:___________________________________ for _____________________________________

Eligibility: In accordance with Pivot Charter Policy, Medication Administration, and CA Education Code, only students

who meet the following descriptions may possess and self-administer medications: (1) Students with special medical

needs such as asthma and/or severe allergies or who are subject to anaphylactic reactions and may require emergency

medications (i.e., asthma inhaler or epinephrine auto-injector [“Epi-pen”]); and (2) Students who require frequent

administrations of non-prescription medications or prescription medications that are not controlled substances.

Healthcare Provider: The student named above has (1) asthma or an allergy that could result in an anaphylactic reaction

and may require emergency medications; or (2) a condition that requires frequent administration of a prescription or non-

prescription medication. The medication is not a controlled substance. This student is capable of, has been instructed on

the procedures for, and has demonstrated the skill to self-administer this medication as directed on the form Medication

Authorization for Pivot Charter School Students. Please allow him/her to self-administer the medication during school

hours and as otherwise documented by their healthcare provider.

This student will not require adult supervision while taking this medication.

Physician signature/date_____________________________________________________

Parent/Guardian: I give consent to Pivot Charter Schools to allow my child to self-administer this medicine at school. I

understand that my child and I assume responsibility for the proper use and safekeeping of this medicine. If the

medication that is prescribed for my child is for the treatment of asthma or anaphylactic reactions, I agree to provide a

supplementary supply of the medication that will be kept by the school in a location to which my child has immediate

access. I absolve the Pivot Charter School Board of Education and their agents and employees from any and all liability

whatsoever that may result from my child possessing or taking this medicine at school. I further consent for the

information about my child’s health condition and related medications to be shared with appropriate school staff as

necessary for the safety of my child.

Parent or Guardian signature/date_______________________________________________________

Student: (please initial and sign)

_____ I am capable of taking this medicine as recommended and accept this responsibility.

_____ I will keep it secure at all times and will not share it with others. I further acknowledge it is inappropriate and

dangerous to share medications with peers, and that any such action will result in the Site Administrator notifying my

parent/guardian and possible loss of self-administration privileges.

_____ I agree to verbally notify an Educational Coordinator/Teacher if there is a problem with any medication, supplies or

equipment, and/or I need assistance with any aspect of taking my medication during school hours.

Student signature/date______________________________________________________

PR-E-LP-023

Page 1 of 2 PR-E-LP-023 (Revised October 11, 2011) CAREGIVER’S AUTHORIZATION AFFIDAVIT www.saccourt.ca.gov

CAREGIVER’S AUTHORIZATION AFFIDAVIT Use of this affidavit is authorized by Part 1.5 (commencing with Section 6550) of Division 11 of the California Family Code. Instructions: Completion of items 1-4 and the signing of the affidavit is sufficient to authorize enrollment of a minor in school and authorize school-related medical care. Completion of items 5 through 8 is additionally required to authorize any other medical care. Print clearly. The minor named below lives in my home and I am 18 years of age or older. 1. Name of minor: ______________________________________________________________ 2. Minor’s birth date: ____________________________________________________________ 3. My name: __________________________________________________________________ (adult giving authorization) 4. My home address: __________________________________________________________ __________________________________________________________ 5. [ ] I am a grandparent, aunt, uncle, or other qualified relative of the minor (see back of this form for a definition of “qualified relative”). 6. Check one or both (for example, if one parent was advised and the other cannot be located): [ ] I have advised the parent(s) or other person(s) having legal custody of the minor of my intent to authorize medical care, and have received no objection. [ ] I am unable to contact the parent(s) or other person(s) having legal custody of the minor at this time, to notify them of my intended authorization. 7. My date of birth: _____________________________________________________________ 8. My California driver’s license or identification card number: ___________________________ Warning: Do not sign this form if any of the statements above are incorrect, or you will be committing a crime punishable by a fine, imprisonment, or both. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Dated: __________________________ Signed: _________________________________________

NOTICES 1. This declaration does not affect the rights of the minor’s parents or legal guardian

regarding the care, custody, and control of the minor, and does not mean that the caregiver has legal custody of the minor.

2. A person who relies on this affidavit has no obligation to make any further inquiry or investigation.

3. This affidavit is not valid for more than one year after the date on which it is executed.

PR-E-LP-023

Page 2 of 2 PR-E-LP-023 (Revised October 11, 2011) CAREGIVER’S AUTHORIZATION AFFIDAVIT www.saccourt.ca.gov

ADDITIONAL INFORMATION

TO CAREGIVERS: 1) “Qualified relative”, for purposes of item 5, means a spouse, parent, stepparent, brother, sister,

stepbrother, stepsister, half-brother, half-sister, uncle, aunt, niece, nephew, first cousin, or any person denoted by the prefix “grand” or “great” or the spouse of any of the persons specified in this definition, even after the marriage has been terminated by death or dissolution.

2) The law may require you, if you are not a relative or a currently licensed foster parent, to obtain a

foster home license in order to care for a minor. If you have any questions, please contact your local department of social services.

3) If the minor stops living with you, your are required to notify any school, health care provider, or health care service plan to which you have given this affidavit.

4) If you do not have the information requested in item 8 (California driver’s license or I.D.), provide

another form of identification such as your social security number or Medi-Cal number. TO SCHOOL OFFICIALS: 1) Section 48204 of the Education Code provides that this affidavit constitutes a sufficient basis for a

determination of residency of the minor, without the requirement of a guardianship or other custody order, unless the school district determines from actual facts that the minor is not living with the caregiver.

2) The school district may require additional reasonable evidence that the caregiver lives at the

address provided in item 4. TO HEALTH CARE PROVIDERS AND HEALTH CARE SERVICE PLANS: 1) No person who acts in good faith reliance upon a caregiver’s authorization affidavit to provide

medical or dental care, without actual knowledge of facts contrary to those dated on the affidavit, is subject to criminal liability or to civil liability to any person, or is subject to professional disciplinary action, for such reliance if the applicable portions of the form are completed.

2) This affidavit does not confer dependency for health care coverage purposes.

California Department of EducationCharter Schools Division Revised October 2019

Charter School Complaint Notice and Form

Instructions for Charter Schools: Add your charter school authorizer information to the form before sharing with parents and posting to your website by completing the five blank fields on the following page under the section titled Complaint Procedures. The completed section will look similar to this:

Name of Charter School Authorizer

Street Address City, State, and Zip Code

Email Phone

If you have questions about completing this form, please contact the Charter Schools Division by phone at 916-322-6029 or via email at charters@cde.ca.gov. Information for Parents: Please review the information on the Charter School Complaint Notice web page at https://www.cde.ca.gov/sp/ch/cscomplaint.asp for information on how to obtain the correct form from your charter school.

Charter School Complaint NoticeCalifornia Education Code Requirements California Education Code (EC) Section 47605(d)(4) (https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=47605&lawCode=EDC) states the following: ■ A charter school shall not discourage a pupil from enrolling or seeking to enroll in a charter school for

any reason, including, but not limited to, academic performance of the pupil or because the pupil exhibits any of the following characteristics:

■ Academically low-achieving ■ Economically disadvantaged (determined by eligibility for any free or reduced price meal

program) ■ English learner ■ Ethnicity ■ Foster youth ■ Homeless ■ Nationality ■ Neglected or delinquent ■ Race ■ Sexual orientation ■ Pupils with disabilities

■ A charter school shall not request a pupil's records or require the parent, guardian, or pupil to submit

the pupil's records to the charter school before enrollment.

■ A charter school shall not encourage a pupil currently attending the charter school to disenroll from the charter school or transfer to another school for any reason (except for suspension or expulsion).

■ This notice shall be posted on a charter school's Internet website and a charter school will provide copies of this notice (1) when a parent, guardian, or pupil inquires about enrollment; (2) before conducting an enrollment lottery, and (3) before disenrollment of a pupil.

Complaint Procedures In order to submit a complaint, complete the Charter School Complaint Form and submit the form to the charter school authorizer, electronically or in hard copy, to the following location:

Charter School Complaint FormName: Email Address:

Mailing Address:

Date of Problem: Phone Number:

Charter School (include address):

Basis of complaint (check all that apply):

Pupil was discouraged from enrolling or seeking to enroll in the charter school.

Records were requested to be submitted to the charter school before enrollment.

Pupil was encouraged to disenroll from the charter school or transfer to another school.

Please provide further details:

Please file this complaint with the authorizer of the charter school listed on the preceding page electronically or in hard copy.

California Education Code (EC) Section 47605(d)(4) allows a parent or guardian to submit a complaint to the charter school authorizer when a charter school discourages a pupil's enrollment, requires records before enrollment, or encourages a pupil to disenroll. Please identify the basis for this complaint below, with specific facts, which support your complaint.