East Orange Community Charter School



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East Orange Community Charter Schoolc:\users\vcoleman\appdata\local\microsoft\windows\temporary internet files\content.ie5\h4q35v1i\mc910218827[1].jpg

99 Washington Street --- East Orange, NJ 07107

Tele #: (973) 996-0400

Fax #: 996-0398

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

  1. 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: ________________________________

(973) 996-0400 x________

(973) 996-0398 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

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