East Orange Community Charter School

East Orange Community Charter School

99 Washington Street --- East Orange, NJ 07107

Tele #: [phone]

Fax #: [phone]

www.theeoccs.org

Welcome to East Orange Community Charter School,

You have chosen to provide your child with an educational experience that will be exciting as well as challenging.
Our mission is to “educate the whole child” by ensuring that your child’s academic, educational and social development needs are met to allow them to reach and/or exceed their full potential, in spacious and safe-learning environments.
Please review and complete the registration information enclosed and return these forms to the Office of Student Enrollment, in order for the registration process to be finalized.
Thank you for selecting East Orange Community Charter School.


Board of Trustees’

Mission Statement

“To govern and ensure that the

highest-accepted, educational

and technological standards are

provided to the students by a

highly-qualified staff, in a clean, fun

and safe-learning environment.

To also ensure that parents are

recognized as the “prime educators”

of their children. And, we

believe that parents/guardians/

families and community involvement

is paramount in “educating

the whole child”.

Adopted: August 10, 2010
Sincerely,


Harvin T. Dash

Principal/Executive Director

HTD/vac

Enclosures
revised: 2-18-2011

EAST ORANGE COMMUNITY CHARTER SCHOOL STUDENT REGISTRATION APPLICATION

TODAY’S DATE:

Student’s Name (Last First M. I.) (Name as indicated on Birth Certificate)

Date of Birth

Gender

Grade

Male

Female

Address (Street Apt.# )

City State Zip Code

City of Birth

State of Birth [USA]

Country of Birth

Race or Ethnicity [Required by New Jersey Department of Education [NJDOE] Check One ✓

Hispanic or Latino

American Indian

Asian

Black

Pacific

White

Other

Name of Parent/Guardian (Mother)

Name of Parent/Guardian (Father)

Address

Address

Home Telephone #

Cell #

Home Telephone #

Cell #

Work #

Other #

Work #

Other #

Check ✓ one

Single

Married

Separated

Divorced

What is the primary Language spoken in the Home? Check ✓ one

Total number in household

# Adults

# Children

English

Spanish

French Creole

Other

DO YOU CURRENTLY HAVE OTHER CHILDREN THAT ATTEND EAST ORANGE COMMUNITY CHARTER SCHOOL? If yes, please indicate their NAME and GRADE.

SIBLING’S NAME

GRADE

SIBLING’S NAME

GRADE

Does your child have Health Insurance ?

Yes

No

2. Name of Health Insurance Provider.

Please provide name and phone numbers for persons authorized to assume responsibility for your child when parent/guardian is not available. Also, please make sure that the person{s} named below has consented to being contacted, if needed.

1. Name

Address

Telephone

Relationship to your child

2. Name

Address

Telephone

Relationship to your child

3. Name

Address

Telephone

Relationship to your child

Over ➙ ➙ ➙

STUDENT REGISTRATION [Continued]
School your child currently attends? {Must answer this question}
School Name		Location				Telephone #
Please provide information regarding any concerns you may have about your child’s growth and development, academic achievement, social development, etc.
Please advise if a non-custodial parent is prohibited, by law, to have contact with the student. If yes, please provide documents (court) related to this matter. Yes No
Please indicate √ how you heard about EOCCS.
Newspaper Ad	Friend / Relative		Radio / Cable Station	Referral			Other
By my signature below, I attest that the information provided herein is true and correct.
Signature					Date

Thank you for completing this information.

EOCCS/vac

Revised: 2-28-2011

{ 2 }

EAST ORANGE COMMUNITY CHARTER SCHOOL PARENT AGREEMENT
Student’s Name (Last First M. I.) (Name as indicated on Birth Certificate)	Date of Birth		Gender		Grade
			Male	Female
Address (Street Apt #.)	City State Zip Code
Name of Parent/Guardian	Contact Phone #
I, _____________________________________________________________ have chosen to enroll my child Parent / Guardian ______________________________________________, into East Orange Community Charter School Name of Student (EOCCS) and I agree to the following terms and conditions: to ensure that my child arrives on time and attends school daily, {notwithstanding any illness or emergencies}. to ensure that my child will dress in the EOCCS’ uniform in accordance with the Uniform Dress Code Policy that has been established by the EOCCS’ Board of Trustees. to provide EOCCS with any relevant documents pertaining to my child’s academic performance; such as an IEP, school transcripts, etc. to assist my child with all homework assignments and ensure that he or/she is prepared with their assignments. to keep my contact and emergency contact information updated and current. that I believe that parents/guardians are the first educators of our children. As such, I agree to Volunteer at EOCCS as deemed appropriate and in accordance with the Volunteer Procedures established by EOCCS. that I have been informed by EOCCS’ staff -- that in the event that I relocate to a different district, but still maintain my child’s enrollment at EOCCS that I will inform EOCCS and also go to the new resident school district and secure an appropriate transfer from that new district back to EOCCS. to notify EOCCS of any changes in my child’s status at EOCCS, i.e., relocation, absenteeism, illness, transfer, etc.
SIGNATURE of Parent/Guardian		Date

EOCCS/vac

Revised: 2-28-2011

EAST ORANGE COMMUNITY CHARTER SCHOOL STUDENT MEDICAL TREATMENT CONSENT
Student’s Name (Last First M. I.) (Name as indicated on Birth Certificate)		Date of Birth		Gender		Grade
				Male	Female
Address (Street Apt #.)		City, State Zip Code
Name of Parent/Guardian		Contact Phone #
I, ____________________________________________________________, hereby grant permission to the designated East Orange (Parent/guardian’s Name) Community Charter School staff member to conduct the following treatments, screenings, and/or exams, as deemed appropriate by the School Physician and/or School Nurse for the sole purpose of detecting Vision, Hearing, Speech difficulties and/or preventing disease, infection and/or other illnesses. These exams/screenings are in compliance with the New Jersey Department of Education’s regulations and guidelines and will include: Medical / Physical Examination and Evaluation Nurses’ Treatments and Evaluations Hearing Screenings Vision Screenings Speech and Language Screening Kindly complete the emergency and physician contact information below. This form will be filed with the school’s medical office for reference, as needed.
Emergency Contact – Name	Relationship to Student		Emergency Contact #
Name of Child’s Physician	Address		Physician’s Telephone #
By signing below I understand that I will be notified about these examinations and screenings as they are scheduled. Furthermore, I extend permission for any further follow-up that might be necessary.
Signature of Parent/Guardian			Date

EOCCS/vac

Revised: 2-28-2011

EAST ORANGE COMMUNITY CHARTER SCHOOL STUDENT BLANKET PERMISSION FORM
Student’s Name (Last First M. I.) (Name as indicated on Birth Certificate)	Date of Birth		Gender		Grade
			Male	Female
Address (Street Apt #.)	City, State Zip Code
Name of Parent/Guardian	Contact Phone #
This is to certify that I, _____________________________________________________ grant permission for my Parent / Guardian child________________________________________, to participate in the following EOCCS-sponsored activities: Name of Student PICTURE / PHOTO OPS: {i.e., EOCCS -- Class Pictures, school pictures, (i.e., school brochures, annual reports, yearbooks, newspaper ads, Web Site and other public relation videos, student programs, etc., that will be used in the course of student recruitment and/or school public and community relations activities}. TO BE TRANSPORTED: {in the event of an emergency -- other than medical -- or from EOCCS’ site-to-site for school specials -- Art, Math, Technology/Technology Lab, Physical Education, School Library, Book Fairs; local agencies as required, and other EOCCS’–sponsored activities/ programs, where applicable.} TO BE TRANSPORTED TO A MEDICAL FACILITY: {In the event of a “medical emergency”, to be transported to the nearest hospital -- East Orange General Hospital -- or appropriate medical facility.} PARTICIPATE IN OFF-PREMISES EDUCATIONAL FIELD TRIPS {i.e., neighborhood businesses (museums, fire houses, parks, libraries, etc., as authorized by the Principal/Executive Director/and/or Board of Trustees}. ALL REASONABLE SAFETY PRECAUTIONS WILL BE TAKEN, BUT IT IS UNDERSTOOD THAT EAST ORANGE COMMUNITY CHARTER SCHOOL’S STAFF AND THE PLACE(S) VISITED, WILL NOT BE RESPONSIBLE FOR LOSS OF -- OR DAMAGE TO -- PERSONAL PROPERTY.
SIGNATURE OF PARENT/GUARDIAN		DATE

EOCCS/vac

Revised: 2-28-2011

EAST ORANGE COMMUNITY CHARTER SCHOOL REQUEST FOR RELEASE OF SCHOOL RECORDS
Student’s Name (Last First M. I.) (Name as indicated on Birth Certificate)	Date of Birth	Gender		Grade
		Male	Female
Address (Street Apt #.)	City, State Zip Code
Name of Parent/Guardian	Contact Phone #

TODAY’S DATE
TO: (Name of School)
Address of School
Telephone # of school
Please provide the following √ student records for the above-named student to East Orange Community Charter School:
Student Transfer Information		Student Health Appraisal (A-45) Immunization Records			Discipline Records
Report Card for		Standardized Test Scores			Child Study Team / Individual Education Plan (IEP) Records
Discipline Records		Other (Specify)
Please send records to: East Orange Community Charter School 99 Washington Street East Orange, New Jersey 07017 Attention: Office of Student Enrollment			If you have any questions, please call: From: ________________________________ [phone] x________ [phone] Fax #
I hereby authorize the RELEASE of all records-- as requested-- for my child, named above, to the East Orange Community Charter School. Thank you.
Signature of Parent / Guardian						Date

EOCCS/vac

Revised: 3-8-2011