Editing previous response:

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Student Registration

Dear Parent or Guardian:

Thank you for enrolling your child(ren) in L. Hollingworth School.

As a charter public school, we are pleased to offer you a tuition-free educational choice. Completing the online registration application is the first step in enrolling your student. The online registration contains essential documents, including permission forms, special education placement forms, medication notification, and emergency procedure information.

In the second step, an L. Hollingworth School office staff member will contact you to schedule a New Student Orientation Meeting with you and your student, unless your student is an incoming kindergartener.

Please read these forms carefully, complete them thoroughly, and submit them once completed. An office staff personnel will be in contact with you shortly.

We are pleased you have chosen our school for your child and look forward to working with you and your student to achieve educational excellence.

Sincerely,

The Leadership Team

Please complete the form below. Required fields marked with an asterisk *

Section 1- Student Information

Last Name:*

Answer Required

First Name:*

Answer Required

Middle Name:

Answer Required

Grade in the fall: *

Answer Required

Home Telephone:*

Answer Required

Address

Street Address*

Answer Required

City*

Answer Required

State*

Answer Required

Zip/Postal*

Answer Required

City of birth: *

Answer Required

Sex:*

Answer Required

Male

Female

Date of birth: *

Answer Required

Please check the box that applies to this student (optional):

Answer Required

Native American or Aleutian

Asian or Pacific Islander

African America

Hispanic/Latino

Caucasian, non-Hispanic origin

Language spoken in home: *

Answer Required

Is child proficient in English? *

Answer Required

YES

Other language child speaks and/or reads:

Answer Required

PREVIOUS SCHOOL INFORMATION

Name of last school attended: *

Answer Required

Starting date attended:*

Answer Required

Last date attended:*

Answer Required

Telephone Number:*

Answer Required

Address

City*

Answer Required

State*

Answer Required

Zip/Postal*

Answer Required

School district in which parent or guardian lives: *

Answer Required

FAMILY INFORMATION

Father

Last Name:

Answer Required

First Name:

Answer Required

Employer:

Answer Required

English proficient?

Answer Required

YES

Other language spoken and/or read:

Answer Required

Daytime phone:

Answer Required

Evening phone:

Answer Required

Mother

Last Name:

Answer Required

First Name:

Answer Required

Employer:

Answer Required

English proficient?

Answer Required

YES

Other language spoken and/or read:

Answer Required

Daytime phone:

Answer Required

Evening phone:

Answer Required

Step-Parent

Last Name:

Answer Required

First Name:

Answer Required

Employer:

Answer Required

English proficient?

Answer Required

YES

Other language spoken and/or read:

Answer Required

Daytime phone:

Answer Required

Evening phone:

Answer Required

Guardian 1

Last Name:

Answer Required

First Name:

Answer Required

Employer:

Answer Required

English proficient?

Answer Required

YES

Other language spoken and/or read:

Answer Required

Daytime phone:

Answer Required

Evening phone:

Answer Required

Guardian 2

Last Name:

Answer Required

First Name:

Answer Required

Employer:

Answer Required

English proficient?

Answer Required

YES

Other language spoken and/or read:

Answer Required

Daytime phone:

Answer Required

Evening phone:

Answer Required

STUDENT LIVES WITH

Answer Required

Parents

Father & stepmother

Mother & stepfather

Mother only

Father only

Guardians

Court-Appointed Guardians

Foster Parents

INFORMATION ON OTHER CHILDREN IN HOME

1. Child's Name:

Answer Required

Date of Birth:

Answer Required

Grade:

Answer Required

2. Child's Name:

Answer Required

Date of Birth:

Answer Required

Grade:

Answer Required

3. Child's Name:

Answer Required

Date of Birth:

Answer Required

Grade:

Answer Required

4. Child's Name:

Answer Required

Date of Birth:

Answer Required

Grade:

Answer Required

5. Child's Name:

Answer Required

Date of Birth:

Answer Required

Grade:

Answer Required

6. Child's Name:

Answer Required

Date of Birth:

Answer Required

Grade:

Answer Required

7. Child's Name:

Answer Required

Date of Birth:

Answer Required

Grade:

Answer Required

Section 2 - Request for release of Student Records

Please forward the transcript(s) of*

Student's full name

Answer Required

born*

Student's DOB

Answer Required

who enrolled in grade*

Answer Required

on *

Date of enrollment

Answer Required

It is requested that information about courses taken, grades earned to the date of withdrawal, standardized test results, parent-teacher conferences, health records, psychologist reports and other important data be included.

In addition, if the student was receiving special education services, please forward these records, including all evaluation reports, Multidisciplinary Team Reports and Individual Education Plans or had a 504 plan.

The parent or legal guardian who has signed below has been informed of this transfer request and grants permission for the information to be sent.

Thank You,
L. Hollingworth School

Send records to:
L. Hollingworth School
653 Miami Street
Toledo, OH 43605
419-705-3411 (Fax) 419-720-4923

Parents

Please sign and complete the information below as a request for release of your child’s student records.

Name and address of school last attended:

School Name*

Answer Required

School Street Address*

Answer Required

City*

Answer Required

State*

Answer Required

Zip/Postal*

Answer Required

Phone Number*

Number Required

Parent/Guardian electronic signature*

Answer Required

Section 3- Emergency Contact & Medical Information

Parent/Guardian Information

Parent 1

First Name*

Answer Required

Last Name*

Answer Required

Email 1*

Answer Required

Mobile Phone*

Number Required

Home Phone*

Number Required

Work Phone*

Number Required

Address

Street Address*

Answer Required

City*

Answer Required

State*

Answer Required

Zip/Postal*

Answer Required

Parent 2

First Name

Answer Required

Last Name

Answer Required

Email 1

Answer Required

Mobile Phone

Number Required

Home Phone

Number Required

Work Phone

Number Required

Alternative Emergency Contacts

Primary Emergency Contact

First Name

Answer Required

Last Name

Answer Required

Email 1

Answer Required

Mobile Phone

Number Required

Home Phone

Number Required

Work Phone

Number Required

Address

Street Address

Answer Required

City

Answer Required

State

Answer Required

Zip/Postal

Answer Required

Secondary Emergency Contact

First Name

Answer Required

Last Name

Answer Required

Email 1

Answer Required

Mobile Phone

Number Required

Home Phone

Number Required

Work Phone

Number Required

Address

Street Address

Answer Required

City

Answer Required

State

Answer Required

Zip/Postal

Answer Required

Medical Information

Hospital/Clinic Preference*

Answer Required

Physician's Information

Physician's Name*

Answer Required

Phone Number*

Number Required

Insurance Company*

Answer Required

Insurance Co. Phone Number*

Number Required

Allergies/ Special Health Considerations

Answer Required

I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event than neither parent/guardian can be reached in the case of an emergency.*

Answer Required

Yes

Parent/Guardian Electronic signature*

Answer Required

Today's Date*

Answer Required

I give permission for my child to go on field trips. I release L. Hollingworth School for Talent and Gifted and individuals from liability in case of accident during activity related to L. School for Talented and Gifted as long as normal safety procedures have been taken.*

Answer Required

Yes

Parent/Guardian Electronic signature

Answer Required

Today's Date*

Answer Required

Additional Adults May Pick Up My Child At Dismissal:*

Please add the full names, relationship to child, and phone numbers****

Answer Required

L. HOLLINGWORTH SCHOOL PLEDGE

Parent name

Answer Required

Parent of*

Student name

Answer Required

support the mission and educational goals of L. Hollingworth School.

I resolve to show that I am an interested and responsible parent:

1. I will send my child to school every day dressed in the school uniform described in the student handbook.

2. I will send my child to school every day, ready to learn.

3. I will send my child to school every day healthy, clean, and well-cared for.

4. I will teach my child to be well-behaved and show good manners.

5. I will notify the school when my child is ill or is going to be absent.

6. I will teach my child to respect all property and to take care of all school supplies, books, and equipment.

7. I will attend conferences about my child.

8. I will support the school and my child's teacher in helping my child follow the code of conduct.

9. I will volunteer to work with my child's teacher in school or at home.

10. I will volunteer at my child's school at least 10 hours per school year.

Student's Name*

Answer Required

Parent or Guardian Electronic Signature*

Answer Required

Date*

Answer Required

INTERNET ACCEPTABLE USE POLICY

Prior to receiving authorization to use the Internet, students and their parents/guardians must sign the following permission and contact document electronically.

Parents

I permit my child to participate in the use of the Internet, a worldwide telecommunication network. I realize that (s)he will be able to access major networks throughout the world using the Internet. I understand that this access is designed and intended for educational purposes only. I also understand that the student will receive instruction in the appropriate use of this resource.

I realize the Internet contains material that is inappropriate for school purposes. I support the school's position that students are responsible for not accessing such material. Such unacceptable use of the network will result in the suspension of all privileges. I will not hold L. Hollingworth School accountable for unsuitable materials acquired by the student through Internet usage for school.

Student's Name *

Answer Required

Parent or Legal Guardian Electronic Signature*

Answer Required

Date*

Answer Required

Students

I Will abide by the Internet Acceptable Use Policy. I understand that the Internet contains material inappropriate for school use and, therefore, will take personal responsibility not to access this material. I recognize that it is impossible for L. Hollingworth School to prevent access to all controversial materials, and I will not hold them responsible for materials found or acquired on the network. I further understand that any violation of the regulations in this policy is unethical and may constitute a criminal offense. Should I commit any violation, my access privileges may be revoked and appropriate school discipline and/or legal action may be taken.

Student's Electronic Signature*

Answer Required

Grade*

Answer Required

Date*

Answer Required

FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT (FERPA)/MEDIA RELEASE

I give my permission to L. Hollingworth School to provide information concerning school activities with my child to the general news media. I also give my permission for my child's name, portrait, picture, or voice to be used (both now and in the future) for display or in promotional/marketing material in a variety of mediums for the school, and/or in local media coverage of academy events.

There may be times during the school year when the school, news media or others wish to use artwork created by your child at the academy for use in print, video, Internet or other communications methods.

Also, I acknowledge that subsequent to the date my child ceases to be enrolled at L. Hollingworth School, I may revoke the forgoing grant of permission by providing L. Hollingworth School, with specific written notice of such revocation.

Student's Name*

Answer Required

Parent or Legal Guardian Electronic Signature*

Answer Required

Date*

Answer Required

FIELD TRIP PERMISSION FORM

I the parent/guardian of*

student name

Answer Required

grant permission for my child to attend L.Hollingworth School trips provided:

I am notified in writing or verbally prior to the field trip.
I am given an opportunity to sign a specific field trip permission form.

If I fail to sign a specific field trip permission form, I agree that this generic online form may be used in place of the specific field trip form.

I further agree that this form may only be used as a permission form in the event of an emergency for which I am unable to sign.

I authorize any medical treatment in case of an emergency and agree that I am responsible for the cost of such treatment.

The undersigned agrees to release, hold harmless and indemnify L. Hollingworth School, its agents, representatives, and employees from all claims, damages, or other liabilities for injuries to my child which are not the result of gross negligence, intentional neglect, or willful conduct by the school or its agents, representatives, or employee.

Parent or Legal Guardian Electronic Signature*

Answer Required

Date*

Answer Required

STUDENT RESIDENCY

By completing this questionnaire, you help the school comply with the McKinney-Vento Act, Title X, Part C of the No Child Left Behind Act. Your truthful and accurate answers help the school identify services that the student may be eligible to receive.

Student's name*

Answer Required

Date of birth*

Answer Required

Age*

Answer Required

Sex*

Answer Required

Male

Female

Parent(s) name*

Answer Required

Phone number*

Number Required

Address

Street Address*

Answer Required

City*

Answer Required

State*

Answer Required

Zip/Postal

Answer Required

1. Where is the student living now?

Check one box

Answer Required

In a shelter

In a car

in a motel or hotel

In a trailer park or campsite

With more than one family in a house or apartment

None of the above

If you checked the box marked "none of the above" you do not have to complete the remainder of this form. Please sign electronically below.

Does the living arrangement marked in Question 1 results from a loss of housing or economic hardship?

Answer Required

Yes

Unsure

The student lives with:

Answer Required

1 parent

2 parents

1 parent and another adult

A relative, friend(s) or other adult(s)

Alone with no adults

An adult who is not the parent or legal guardian

Parent or Guardian Electronic Signature

Answer Required

Date

Answer Required

FOR SCHOOL USE ONLY

FOR SCHOOL USE ONLY

Answer Required

Student not covered by McKinney-Vento Act

Student covered by McKinney-Vento Act

Follow-up required

Contact person at the student's school who may know of the family situation: Name and phone number.

Answer Required

HOME LANGUAGE SURVEY

Student's name*

Answer Required

Grade*

Answer Required

Date of Birth*

Answer Required

Parent(s) name*

Answer Required

Parents phone number*

Answer Required

Address

Street Address*

Answer Required

City*

Answer Required

State*

Answer Required

Zip/Postal*

Answer Required

What was the first language your child learned?*

Answer Required

What language is spoken most often by your child?*

Answer Required

What languages, other than English, are spoken in the home?*

Answer Required

Was your child receiving help with English in their previous school?*

Answer Required

Comments

Answer Required

Electronic signature of Parent/Guardian*

Answer Required

Date*

Answer Required

SPECIAL EDUCATION RECORDS REQUEST

Please complete this form for all new students who received special education services at their previous school. This request will then be forwarded to the special education department of your child's previous school district.

Student name

Answer Required

Grade

Answer Required

Date of Birth

Answer Required

Parent/Guardian name

Answer Required

Phone number

Number Required

Address

Street Address

Answer Required

City

Answer Required

State

Answer Required

Zip/Postal

Answer Required

Previous district attended

Answer Required

Building

Answer Required

Address

Street Address

Answer Required

City

Answer Required

State

Answer Required

Zip/Postal

Answer Required

Disability

Answer Required

District contact person

Answer Required

Phone

Number Required

Date of last Individual Education Plan (IEP)

Answer Required

Please upload a copy of student's IEP

If you are unable to upload a file, please submit a copy to the the office.

Answer Required

Choose a file or drag it here.

Please sign electronically below so that we may request your child's special education record, including all evaluation reports, Multidisciplinary Team Reports and Individual Education Plans.

I grant permission for L. Hollingworth School to receive the special education records of my child

child's name

Answer Required

from

name of school district

Answer Required

Electronic signature of Parent/Guardian

Answer Required

Date

Answer Required

FOR SCHOOL USE ONLY

Date form forwarded to special education teacher

Answer Required

Date records requested from previous school

Answer Required

Date records received from previous school

Answer Required

INCLUSIVE EDUCATION

IDEIA 2004 states that, to the maximum extent appropriate, children with disabilities should be educated with children who are not disabled. Special classes, separate schools or other removal of children with disabilities from the regular educational environment should occur only when the nature or severity of the disability of a child is such that education within regular classes with the use of supplementary aids and services cannot be achieved satisfactorily. L. Hollingworth School embraces this philosophy, believing that special education students can best be educated in the regular classroom. Our teachers accept responsibility for all students in their classroom and modify, accommodate and adjust teaching techniques and classroom activities to meet the learning abilities of all children.

Please indicate on the Special Education Records Request form in this online registration packet if your child has an Individual Education Plan in place. You will receive an invitation from the intervention specialist or resource teacher to attend and IEP meeting, if necessary, within the first month of your child's enrollment at our academy.

The following electronic signature indicates that I understand the instructional philosophy of the school.

Electronic signature of Parent/Guardian

Answer Required

Date

Answer Required

The academy is participating in an effort to identify, locate, and evaluate all children who may have disabilities. For more information regarding assistance for students with disabilities or if you suspect a child may have a disability, please contact the school leader.

AFFIRMATION OF PRIOR DISCIPLINE RECORD

Check the appropriate box, provide all appropriate information and electronically sign this online document.

I affirm that information provided here is true and that any false statements may result in forfeiting my child's enrollment privileges at L. Hollingworth School.*

Answer Required

The undersigned affirms that has not been suspended in school or out of school or expelled from any school.

The undersigned affirms that has been suspended or expelled from a school.

If the student has been suspended or expelled, please provide the L. Hollingworth School, date of suspension, and/or expulsion, along with a detailed description of the incident(s).

Electronic signature of Parent/Guardian*

Answer Required

Date*

Answer Required

Signature of L. Hollingworth School Staff Member

Answer Required

Date copy sent for verification

Answer Required

Former school district

Former school street address*

Answer Required

City*

Answer Required

State*

Answer Required

Zip/Postal*

Answer Required

Please check one:*

Answer Required

According to our records, we verify that the information provided above by the parent/student is correct.

According to our records, the information provided by the parent/student is not correct. Appropriate documentation of suspensions and/or expulsions is attached.

Please upload students documentation of suspensions and/or expulsions here.

Answer Required

Choose a file or drag it here.

Signature and title of sending district administrator

Answer Required

Date

Answer Required

GOOGLE MAIL PERMISSION

Students at L. Hollingworth will need to access their G-Mail account to use their Google Drive, which contains documents, slides, and sheets. Students who are participating in a College and Career Readiness class in grades 3-5 and students in grades K-2 who are participating in the Intro to Technology class with Ms. Gerwin will need to use the Gmail (email through google) portion of your child's account for various reasons. They will also use them in their general education classrooms.

The Gmail account will be used for:

Emails within the LHSTG network* (to teachers, or students collaborating on projects)
Access to Naviance (purpose) College and Career Resouces and Electronic Portfolio
Access to Ohio Means Jobs (purpose) Create an online backpack for college and career readiness

The email account will be used for various assignments in class to better prepare them for their future in a college and career. Students are not permitted to use their email account for any illegal, unkind, or inappropriate reasons. They have already signed a computer use contract regarding the importance of respectful, responsible, and CLASSY behavior while on the computer.

If requested, parents and guardians will be able to view student email accounts by contacting Ms. Gerwin ([email protected]) or extension 121 at LHS).

*Students will ONLY be able to send and receive emails that come from within the LHSTG network. They will not be able to contact ANY outside people or organizations.

I understand and give my student permission to continue using a Gmail account through LHSTG for the purposes above. I know that I can revoke this permission at any time by providing written notice or contacting Ms. Gerwin

Electronic signature of Parent/Guardian*

Answer Required

Phone number*

Answer Required

Student Electronic Signature*

Answer Required

Grade*

Answer Required

Documentation Checklist

All required items must be submitted to L. Hollingworth School, 653 Miami Street, Toledo, OH 43605. All checklist documents must be submitted online to reserve a spot!

No partially completed packets will be accepted!

THE CHECKLIST ITEMS BELOW MUST BE SUBMITTED TO COMPLETE THE REGISTRATION PROCESS

The following information is required to enroll in grades kindergarten - 8th at L. Hollingworth School. Please upload or drop their required items file(s) as follows:

Child's original birth certificate (birth record from hospital will NOT be accepted) Your child must turn 5 years of age by August 1st of the current school year to start kindergarten.

If you are unable to upload a file, please submit a copy to the the office.

Answer Required

Choose a file or drag it here.

2 Proofs of Residency - Parent / Guardian, must match name and address on application

(lease, rent receipt, utility bill, etc.) If you are unable to upload a file, please submit a copy to the the office.

Answer Required

Choose a file or drag it here.

Social Security Card

If you are unable to upload a file, please submit a copy to the the office.

Answer Required

Choose a file or drag it here.

Immunization Record

If you are unable to upload a file, please submit a copy to the the office.

Answer Required

Choose a file or drag it here.

Dental Screening

Required for Kindergarten Only

Answer Required

Choose a file or drag it here.

IEP / ETR - if applicable

If you are unable to upload a file, please submit a copy to the the office.

Answer Required

Choose a file or drag it here.

Year End Grade Card from previous year or most current grade card

If you are unable to upload a file, please submit a copy to the the office.

Answer Required

Choose a file or drag it here.

State Test Scores

(Required for Grades 3 - 8) If you are unable to upload a file, please submit a copy to the the office.

Answer Required

Choose a file or drag it here.

Discipline Records from Past Years

(Required for Suspension, expulsions, etc.) If you are unable to upload a file, please submit a copy to the the office.

Answer Required

Choose a file or drag it here.

The school has established a standardized testing program and designated minimum standards acceptable for the early admission of a child to kindergarten. On request of the parents or guardian, the school shall provide testing to children who will be five years of age on or before the first day of January for which admission is requested, and shall admit the children who pass such tests. R.C. 3321.01

Printable Forms

Please print out and complete the Language Usage Survey Application and return to the school office. The Language Usage Survey Application is available in the office if needed.

Language Usage Survey Form

Please print out and complete the Free and Reduced-Price School Meals Application and return to the school office. Free and Reduced-Price School Meals Application is available in the office if needed.

Free and Reduced-Price School Meals Application

Incoming kindergarten students only. Please print out and have your student(s) dentist complete the form and return to the school's office. Kindergarten dental form in the office if needed.

Kindergarten Only Dental Form

Student Fee

$20.00 Non-refundable school/materials fee

Please click the link below

https://www.hollingworthschool.com/apps/form/form.LHOLLING.rEq9U1N.1uf

Family Feedback

Thank you for choosing L. Hollingworth School. We are committed to serving our families in a pleasant and courteous manner. Please take a few minutes to complete this brief questionnaire. Your feedback is very important and your responses will be kept confidential.

How did you hear about L. Hollingworth School?*

Answer Required

Web site

Social Media such as Facebook, Twitter, and Instagram

Friend or relative

Saw building or school sign

Newspaper article

Newspaper ad

Radio Commercial

Television Commercial

Flier

Postcard in mail

Other

Customer Service

If you called for information, was the call answered promptly in a friendly and courteous manner?

Answer Required

Yes

If no, please explain:

Answer Required

If you requested information via the school Web Site, was your request answered promptly in a friendly and courteous manner?

Answer Required

Yes

If no, please explain:

Answer Required

If you visited the school for information, were you greeted promptly in a friendly courteous manner?

Answer Required

Yes

If no, please explain:

Answer Required

Were all of your questions regarding L. Hollingworth School answered to your satisfaction?

Answer Required

Yes

If no, please explain:

Answer Required

In your words

What words would you use to describe the school building and grounds?

Answer Required

Clean

Welcoming

Accessible

School pride displayed

Safe and secure

Unclean

Building, classrooms and office well-marked with signs

Outdated, old

Disorganized

What words would you use to describe the school Web site?

Answer Required

Easy to use

Informative

School pride shown

Quality

Up-to-date information

Relevant information

Appealing

Out-of-date information

Confusing

Not attractive

Difficult to use

Too much information

What words would you describe school advertising you saw?

Answer Required

Quality

Original

Professional

Interesting

Relevant

To the point

Not relevant

Confusing

Not representative of school, students, or community

Misleading

Didn't stand out

What words would you use to describe why you and your child chose L. Hollingworth School?

check all that apply

Answer Required

Quality education

Caring staff

Small school atmosphere

Close to my home

Safe, secure building

Uniforms

School leaders

Family-oriented

Good reputation

Best option available

Attention given to student and family needs

Curriculum focus

Diverse student body

No other choice

Mandatory Screening Process & Procedures

July 31, 2020

Mandatory Screening Process & Procedures

Dear Parents, Guardians, and Foster Caregivers,

The Ohio Department of Education requires that all students entering

Kindergarten and new L. Hollingworth students entering 1st grade receive a vision and hearing screening by November 1st, 2020. ODE requires parents, guardians, and foster caregivers be notified of these screenings by August 1st.

This letter is to inform you that your child will receive these mandatory screenings prior to November 1st, 2020. Screening results will be sent home within 14 days of the screening process being completed.

Given the current circumstances related to Covid-19, this information may change. L. Hollingworth is currently in communication with the Ohio Department of Education and Ohio Department of Health for further guidance on this issue in order to adhere to current health and safety guidelines.

Updates and changes related to these screenings will be shared out as soon as we are notified. If you have any questions or concerns, please feel free to contact me directly at the number listed below.

Sincerely,

Marrissa Gracia

Special Education & Student Ancillary Coordinator

(419)705-3411 ext. 103

L. Hollingworth School

Thank you for your interest in LHS!

LHS is a free public charter school that prepares students for success in college and life. Outstanding educators, more time in school, a college and career readiness curriculum program, and an influential culture of achievement and support to help our students make significant academic gains.

We look forward to meeting with you and welcoming you to the endless opportunities that LHS has to offer.

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