UintahSchool District⁄ K-8 HomeSchool Program
Vernal, UT
Phone: (435) 781-3100 ext. 2840
Fax: (435) 781- 4679
2007-2008 Enrollment Package Instructions and Checklist
Please complete one enrollment package for each student seeking admission to the UintahCountySchool DistrictK-8 HomeSchool Program. Please print clearly with blue or black ink. Be sure to include the student’s name and phone number at the bottom of each page of every form in case the pages of the document become separated. NOTE: Students are not officially enrolled until all completed forms have been submitted and you receive notification of acceptance. Incomplete forms will not be considered. As you complete each item, please mark the box on the checklist below.
If you have any questions or need assistance, please contact us at (435) 781-3100 ext. 2840.
Please complete, sign and submit this Enrollment Checklist with your application.
Required Forms:
Application Form: Please fill out all the information sections. Make sure you provide complete information including full mailing and shipping address. To ensure accurate entry, spell out all abbreviation including street and city names.
Enrollment Acceptance: Please initial the statements on this form acknowledging the expectations for enrollment in the Uintah K-8 program. Also, sign the form indicating that you intend to enroll your student for one academic school year in Uintah County School District K-8 Home School Program if you are accepted.
Agreement for Use of Instructional Property: Uintah County School District K-8 Home School Program has made arrangements to permit families to use related instructional books and materials (instructional property) to facilitate the student’s education while enrolled in the Uintah County School District K-8 Home School Program. Parents will be held responsible for maintaining instructional property and returning items in good working order. Please read the agreement carefully then sign and return it with your enrollment.
Release of Student Records: This form is required to transfer your student’s previous school records. If your student is entering kindergarten or was not previously enrolled in a school, write “not applicable” on the form.
Additional Required Documentation: Include a COPY of the student’s current immunization records, a COPY of the student’s birth certificate, and a COPY of a document showing proof of residency (utility bill, voter registration, local tax documents or other official documents addressed to the parent/legal guardian living with the student).
___ Immunization Record or Card___ Student Birth Certificate
___ Proof of Residency___ Copy of IEP or retention (if applicable)
Application can be mailed to:
UintahCountySchool District/ K-8 HomeSchool Program
Enrollment Processing Center
2300 Corporate Park Drive, Suite 200
Herndon, VA20171
Application for Enrollment in UintahSchool District K-8 HomeSchool Program 2007-2008
This form is required for each student applying to UintahCountySchool District.
Please call (435)781-3100 ext. 2840 with questions.
Student’s Legal Name: ______
First MiddleLast
Student’s Preferred Name: ______Gender: Male Female
Age (as of 9/1/07): ______Date of Birth: ______
Are you requesting a grade or course level placement that differs from the age-appropriate standards? Yes No
BoundarySchool District: ______
Student Mailing/Shipping Address: ______
If you are planning to move or change your mailing address, please be sure to notify UintahCountySchool District as soon as possible.
Shipping occurs periodically throughout the school year for some courses.
Student ID # (if known): ______Social Security Number: ______
Home Phone: ______Cell Phone: ______
Ethnicity (please check one): African American, not Hispanic Native American White, not Hispanic
Hispanic/Latin Asian Muti-racial Decline to state
Other: ______
Student lives with: Both parents Both parents alternately (joint custody) Mother Father Legal Guardian
Family e-mail address (This will be used for correspondence): ______
Type of previous school: Public school Private school Home school Charter school Preschool
Not in school/other, please explain: ______
Please complete all applicable parts:
Name of LastSchool Attended: ______
Address of last School Attended: ______
Phone: ______Fax: ______
Teacher’s Name: ______
Withdrawal Date: ______
Withdrawal Grade Level: K 1 2 3 4 5 6 7 8
Student’s Name: ______
Last First Middle
What is the student’s first/primary language? ______
Are any languages other than English used as a major form of communication in the home? Yes No
If yes, list language other than English spoken in the home by each person:
Student: ______
Father: ______
Mother: ______
Other adult: ______
______School year student first enrolled in a grade K – 12 within the U.S.A.
Example: If a student arrived November 15, 2002. The school year of arrival would be 2002-2003.
This information is left blank for a student born in the USA.)
Language needed for written notices sent home by the school ______
Language needed for oral communication with the home ______
The original HLS form should be placed in the student cumulative file and a copy sent to the District Office.
Has your child participated in any of the following special services? Gifted/Talented Title 1 504 Plan
Special Education/IEP Speech or Language Services ELS (English as a Second language)
Does your student have and IEP? Yes No
Please submit any and all of the following (IEP, Multifactored evaluation, 504 plan) with your application.
Copies must be received to assist in meeting your student’s needs.
Age appropriate Grade Level (please check): K 1 2 3 4 5 6 7 8
Grade Level Applying for (please check): K 1 2 3 4 5 6 7 8
To ensure that your student is placed at the appropriate level, K12 has developed placement tests in math and language arts. These are available at All students must take these placement tests and submit the results in order to enroll in Uintah County School District K-8 Home School Program. These tests and accompanying directions for submission of results are available on line.
You will be contacted by a UintahCountySchool District Placement Specialist shortly after your
student’s enrollment package is received and placement tests have been taken.
Mother’s Name: ______
Last first middle
Mother’s Mailing Address: same as student’s
______
street apt #
______
city county state zip
Work on Federal Property? Yes NoMigrant Worker? Yes No
Name of Employer: ______Occupation: ______
Home Phone: ______Work Phone: ______Cell Phone: ______
Father’s Name: ______
Last first middle
Father’s Mailing Address: same as student’s
______
street apt #
______
city county state zip
Work on Federal Property? Yes NoMigrant Worker? Yes No
Name of Employer: ______Occupation: ______
Home Phone: ______Work Phone: ______Cell Phone: ______
Stepparent/Legal Guardian’s Name: ______
Last first middle
Stepparent/Legal Guardian’s Mailing Address: same as student’s
______
street apt #
______
city county state zip
Work on Federal Property? Yes NoMigrant Worker? Yes No
Name of Employer: ______Occupation: ______
Home Phone: ______Work Phone: ______Cell Phone: ______
Sibling Name Application Status Date of Birth Relationship to Student
Applying this year Not applying this year
Applying this year
Not applying this year
Applying this year
Not applying this year
Applying this year
Not applying this year
Applying this year
Not applying this year
UintahCountySchool District K-8 HomeSchool Program will assign a teacher for your student. In addition, the school program requires that you specify an adult to have the primary responsibility for working with your student on a daily basis. The primary adult may be a parent, legal guardian, or someone else of your choosing. If other than a parent or legal guardian, you will be asked to provide additional information after you enroll. Please designate the primary adult and list this person’s relationship to the student.
Primary Adult’s Name: ______
first middle last
Relationship to student: ______
Home Phone: ______Cell Phone: ______
What language(s) does the primary adult speak? ______
What language(s) does the primary adult write? ______
What language(s) does the primary adult read? ______
If a parent cannot be reached, we will attempt to contact one of the following people in the order listed below.
Contact’s Name: ______Relationship: ______
Home Phone: ______Work Phone: ______Cell Phone: ______
Contact’s Name: ______Relationship: ______
Home Phone: ______Work Phone: ______Cell Phone: ______
The Family Educational Rights and Privacy Act (FERPA) gives parents and students over 18 years of age (“eligible students”) certain rights regarding the student’s education records. One of those rights is the right to consent to disclosures of personally identifiable information contained in the student’s education records.
UintahCountySchool Districtand its designated curriculum provider, K12 Inc., have found that to best serve the student’s education needs, it is necessary to disclose a student’s name and address to the following classes of vendors that provide important services related to your student’s education. In all cases, these vendors will have agreed to ensure the confidentiality of the student’s name and address and to not use the information for purposes other than that contracted for the student’s education needs.
• Suppliers of computers and educational materials for purposes of shipping to and from the student’s home
• Customer care providers that handle overflow calls for K12 Inc.
• Internet service provider
• Companies that enter the student information into a computer database for use by school officials
• Speakers or presenters presenting or participating in synchronous web-conferencing sessions
• Computer professionals that host and maintain K12 Inc.’s student account management systems
• Other contractors and subcontractors that UintahCountySchool Districtand/or K12 Inc. Identify as necessary to providing education services
To best serve the student, UintahCountySchool Districtrequests the following parental consent to disclose the student’s name and address to the specified class of contractors.
I hereby agree that my student’s name and address be provided to the above identified contractors to ensure that UintahCountySchool Districtcan best meet my student’s education needs.
Parent/Guardian’s Signature:______Date:______
Release Information
Do we have your permission to publish the parent’s and student’s name, address, e-mail, and phone number in the student directory?
□Yes □ No
Throughout the year, there are occasions when UintahSchool District. may want to take pictures/videos of your student participating in activities related to the school. We may use, duplicate, broadcast, distribute, and display these pictures to local newspapers, school website, classrooms or for advertising with UintahCountySchool District. We request that you sign this photo/video release for your student to allow us to record on film, tape, or otherwise, to edit such items as desirable or necessary, and to use the student’s name, likeness, image, voice, and performance as outlined above.
Student’s Name: ______
last first middle
□ I give my consent for UintahCountySchool District to use pictures/video of my student.
□ I do NOT give my consent for UintahCountySchool District to use pictures/video of my student.
Parent/Guardian’s Signature: ______Date: ______
Enrollment Acceptance for UintahSchool District K-8 HomeSchool Program 2007-2008
This form is required for each student applying to UintahCountySchool District
Please call (435)781-3100 ext. 2840 with questions
It is the policy of UintahCountySchool District to comply with all federal and state laws prohibiting discrimination. Any person having inquiries concerning such compliance is directed to contact:
UintahCountySchool District
Student Services Director
Address: 635 West 200 South Vernal, UT 84078
Phone: (435) 781-3100
Please initial each of the following statements and sign the bottom of the form.
____ I understand that I am enrolling my student in a public school with attendance requirements that I am expected to meet.
____ I understand that public school enrollment includes participation in the required state testing program, in addition to school district testing requirements.
____ I understand that my student should complete one academic school year in the Uintah County School District K-8 Home School Program.
____ I accept the responsibility to supervise my student in using the curriculum provided by the district. I understand that I must assist my student in meeting all school requirements such as work sample submission and face-to-face meetings with my student’s teacher.
____ I expect to follow the guidance and support of a professional teacher in implementing the curriculum with my student.
____ I understand that student progress is an expected part of Uintah County School District K-8 Home School Program in addition to the attendance hours logged. Teachers will review progress and consider other factors, including parental input, when making student advancement decisions.
____ I understand that I am required to participate in regular telephone conferences with my student’s teacher(s) during normal work hours and that I will be asked to submit work samples.
____ I understand that I am required to provide a computer, printer and Internet access to my student.
____ I accept the responsibility to maintain a working e-mail and Internet connection.
____ I understand that my student will be required to have direct contact each week with a teacher. I understand that a parent or legal guardian must be in the home at all times during contact visits.
Please accept this signed and completed document to enroll ______in the
student name
Uintah County School District K-8 Home School Program for the 2007-2008 academic year. I understand that completion of this enrollment does not guarantee admission into the program.
Parent/Legal Guardian’s Signature: ______
Agreement for Use of Instructional Property 2007-2008
This form is required for each student applying to UintahCountySchool District.
Please call (435)781-3100 ext. 2840 with questions.
Responsible Party is the parent or legal guardian of the student who is enrolling in Uintah County School District K-8 Home School Program.
UintahCountySchool District has made arrangements to permit the family of the student to use certain related instructional books and materials (“Instructional Property”) to facilitate the student’s education while enrolled in UintahCountySchool District, provided that the Responsible Party is willing to accept responsibility for the Instructional Property as set forth below.
Responsible Party herby agrees to the following:
- Use of Instructional Property. UintahCountySchool District shall permit the Student and the Responsible Party to use the Instructional Property listed on the attached Appendix 1 – Instructional Property Schedule. UintahCountySchool District reserves the right to add, change, substitute, add/or delete individual items on the Instructional Property Schedule from time to time.
- Term. Responsible Party’s and Student’s rights to use and possess the Instructional property expires upon the Student’s termination of enrollment. Notwithstanding the foregoing, UintahCountySchool District and K12 Inc. reserve the right to terminate any right to use and possession immediately if either party has reason to believe that Responsible Party is violating any term or condition of this Agreement. Responsible Party shall return all of the Instructional Property as instructed within five (5) days of the termination date in the same condition as delivered, normal wear and tear expected.
- Ownership. At no time shall legal title to or ownership of any of the Instructional Property vest in the Responsible Party or Student, who shall only have the rights to temporary use and possession as provided herein.
- Condition of Instructional Property. Responsible Party aggress to fill out, sign and return the Instructional Property Receipt Acknowledgment Form (to be enclosed with the Instructional Property) to Uintah County School District to acknowledge receipt of the Instructional Property and to affirm that it is all in satisfactory operating condition upon receipt.
- Responsibility of Instructional Property. Responsible Party must maintain the Property at the Responsible Party’s residence set forth as the shipping address in the enrollment form unless the Responsible Party provides thirty (30) days’ written notice and the new address to UintahCountySchool District. Responsible Party shall be solely liable for any loss or damage to the Instructional Property until it is returned and shall take all reasonable precautions to protect it. Responsible Party agrees to inform Uintah County School District of any loss or damage to the Instructional Property from any cause whatsoever within three (3) days of the loss or occurrence of damage. UintahCountySchool District will provide the Responsible Party with a loss report form that will include provisions for the Responsible Party to pay for the lost or damaged instructional Property and, upon receipt, will allow UintahCountySchool District to ship or have shipped replacement Instructional Property.
- maintenance and Repair. Responsible Party is responsible for maintenance and repair of the Instructional Property while in his or her possession and will follow all instructions for Instructional Property requiring repairs as directed by K12 Technical Support and the Warranty Agreement with the Original Equipment manufacturer. Responsible Party is solely responsible for upgrading to new software versions when publicly available, obtaining and installing antivirus file updates, and overall maintenance of each software application provided.
- Use of the Property. Responsible Party agrees that: (i) Instructional Property may be used solely for the education of the Student while enrolled at Uintah County School District and not for the benefit of any other person or for any other purpose, (ii) all Instructional Property shall be used in accordance with Uintah County School District policies and rules and K12’s and the manufacturer’s instructions, (iii) each software application provided shall be subject to, and used in accordance with, the license and/or use agreement that accompanies that software application, (iv) all usage of the instructional Property shall be subject to Uintah County School District policies and rules regarding Network/Internet use and protocol, (v) Responsible Party is solely responsible for ensuring that the software settings, default configurations, and administrative privileges are maintained at the original specified settings that the Instructional Property had upon delivery and will be liable for any resulting damage to the instructional Property, any files, and/or other software applications if these default settings are changed or modified without explicit authorization from K12 Technical Support, and (vi) Responsible Party is solely responsible for keeping User IDs and password confidential to prevent unauthorized usage and understands that passwords should be changes on a monthly basis.
- General indemnity. Responsible party agrees to indemnify, defend and hold harmless Uintah County School District , K12 Inc., and any sponsoring School District or Authority, their respective employees, officers, directors, agents, assignees, and all affiliated companies and/or entitles (“Indemnified parties”) from and against any and all claims, actions, suits, proceedings, costs, expenses (including, without limitation, court costs and attorney fees), damages, obligations, judgments, orders, penalties, fines, injuries, liabilities and losses arising directly or indirectly out of or in connection with any matter covered by this Agreement, other than those caused by Uintah County School District or K12 Inc.
- Disclaimer of Warranties. No indemnified party makes any warranty or representation, either express or implied, as to the value, design, condition, merchantability, or fitness for a particular purpose, or fitness for use of any of the instructinal property. In no event shall any indemnified party be liable for any actual incidental, direct, indirect, special, or consequential damages in connection with or arising out of this agreement, or the existence, furnishing, functioning, usage, or maintenance of any instructional property provided under this agreement.
- Insurance. Responsible Party aggress to maintain at his or her expense adequate insurance to cover damage to the instructional Property by fire, theft, flood, explosion, accident, act of God, or other cause to the full replacement value of the instructional property and agrees that he or she will be financially liable for it regardless of the availability of insurance proceeds.
- Miscellaneous. Responsible Party represents that he or she has the power to bind all of Student’s parents or legal guardians, all of whom shall be bound by these terms. Responsible party cannot amend this Agreement unless accepted in writing by a representative of UintahCountySchool District. This agreement shall constitute the entire agreement between the parties with regard to the Instructional property and prior understanding or representation of any kind shall not be binding on either party, except to the extent incorporated herein. The waiver of any right under this Agreement by either party shall not be construed as a waiver of the same right at a future time or a waiver of any other right under this Agreement. This agreement shall be construed and enforced in accordance with the laws of the state of Utah.
Responsible Party’s Name: ______