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HomeMy WebLinkAboutWA Charter Renewal Application SEVENTH GENERATION OPEN-ENROLLMENT CHARTER RENEWAL APPLICATION AZLEWAY CHARTER SCHOOL CEDAR CREST SCHOOL EDUCATION CENTER INTERNATIONAL ACADEMY EHRHART SCHOOL EVOLUTION ACADEMY GOLDEN RULE CHARTER SCHOOL JUAN B GALAVIZ CHARTER SCHOOL LIGHTHOUSE CHARTER SCHOOL OUTREACH WORD ACADEMY SAN ANTONIO PREPARATORY ACADEMY VANGUARD ACADEMY WESTLAKE ACADEMY CHARTER SCHOOL Deadline: Deliver or Mail to: June 30, 2006 Texas Education Agency 5:00 P.M. Central Time Division of Charter Schools Room 5-107 William B. Travis Building MC-351 1701 North Congress Avenue Austin, TX 78701 Table of Contents Application Instructions and Explanation of Renewal Process 1 Selected Definitions Application Sections Section 1. Current Information in Charter School Tracking System (coversheet) 4 Section 11. Superintendent and Charter Holder Board Chair Contact Information j Section Ill. Governance Structure and Procedures 6 Section IV. Instructional Facilities 9 Section V. Teacher Qualificatioils 10 Section VI. Compliance With Complaint Procedures 12 Section VII. Admissions Polic\ I Section VIII. Special Education Assurances 15 Section IX. Bilingual/ESL. Section 504. and Dyslexia Assurances 16 Section X. Certificate of Acknovv led<gement 17 Contact Information I8 OPEN-ENROLLMENT CHARTER CONTRACT RENEWAL APPLICATION Section I. Current Information in Charter School Tracking System 6 J Charter Holder Name: Tox\n of'Wesil ake Charter School Name: WESTLAKE ACADEMY CHARTER SCHOOL Charter School CotmtN/District 9: 220-810 Generation: 7 MaximuniAppro%ed Enrollment: 900 CradesApproved: K.1.2.33.4.5.6.7.8.9.10J 112 Campuses: 2-10NI NO I "FS I LAKL ACADENI), 26.00 Ottini-,er Road \�esflake_'FX 76102 Grade Lc,,els C I UrMI11% Served: K6.f)1.02.0,.04.04;_0h.07 Geographical Boundare: he Charier aIpplicjti(n and anlcnufill�nl hlisor\ FCIIQCI,that the 1_ojlo;�ill.-diSlrlclim ille Charier,Choo!,,geographic b0UJIdar% ARO),Li. CARROLL!SD DIA1(A N) KFUTR ISD N()RI I I"I.SIF ISD N.B. In the 2005-06 school year. Westlake Academy served students in grades Kindergarten through grade 08. In the 2007-08 school year Westlake Academy will serge students in Kindergarten through grade 9. We were unable to make these updates to the protected Application Cover Page. Cover Letter Amendment Section 11. Superintendent and Board Chair Contact Information The school superintendent and/or the charter holder board chair will be contacted by agency staff if there are Issues to be resolved in any of the sections. Superintendent Contact Information: SUPerintendent's Name: Barbara BrIZUela. Head of School Telephone Number: 817-490-5757 Fax Number: 817-490-5758 E-mail Address: bb1-iZUela'—cvxN estlakeacadenw.org Charter Holder Board Chair Contact Information: Charter Holder Board Chair's Name: Scott Bradlev Telephone Number: 817-337-5565 Fax Number: 817-337-5334 E-mail Address: niavorbradlev a,%ellzoll.11et 111101601741111-Lefi Blank 5 Section III. Governance Structure and Procedure's Before completing the following items, please review TEC, ti��12.121 and 19 TAC 5��100.1033(c')(b)(C')(i) and also relevant port ions of 19 T<4(',�§100.1101-100.1139: these laws and rules are available on the on-line resource page. A. In the table below. please fill in the information requested concernin-the members of the governing body of the charter holder. Please note the following: • The ('01IM717 Coiwei-nlilg colmj)e17S611i0?7 requii-es the charter holder to re1)ort the total(iniouni Of cl)7171(U1(--01711)ellsellion Ihal each hocircl member receives.f-on7 the chcn•ter hohler or charter school.for cn7lj)tnl)ose(i.e., salary. contract work. etc.). • A "reltilive iviihin the th11'cl degree 01 Co17.SUll 0-tlnlill'01'Uf f117/tl'. I'efel'.S 10 ci hOUl'Cl tnenlhel"S'.SI)0I1,S'e, OP the hOU1'cl member .S' of his or her sj)ouse s. 1)(irents, chihfi-en, gi-mXlchllch-en, .S7h1117�5', grwicljwrents. grew-g)'U1X11)(17'elils, nieces, 17e1)hews. 1!7117/.S. imcles, (117(1 gl'eut-gl't117tk,hilCh'e77. Relative(s) Within the Third DeOree of Amount Consanguinity or Affinity(see definition Compensation n. above Also Serving on the Governing Bods Charter Holder Board Office Held Per Year. Received ) I Member's Name from Charter of Charter Holder Holder or Charter School Relation to Board Member Yes;lvo (use the space provided belm� to 1 i list additional relatives) Scott Bradlee Board Chair SO No Fred Held I Board Member SO No i Truitt Bro,,t n 11 i Board Member o Francis Fres i Board Member I SO i No _ Donald Reddinl-I Board Member j S0 I No Lam Corson Board Member $0 No — i Click Here Click Her i Click Here S Click Herc � i Click Here I S Click Her i Click Here $ Click Here i Click Here S Click Here Use the c17-ea ahove if'uciclitional sptice is neeclecl 6 B. If any charter holder board member has a relative «ithin the third degree of consanguinity or affinity(see definition in subsection A) vN ho is receiving or will receive any compensation fi-om the charter holder or the charter school for anv purpose. please fill in the information requested in the table below. Charter Holder Board Relative's Name Relative's Employment Position or Basis !Member's Name for Compensation C. If the charter holder -overning bodv has created a secondary oovernina body. commonly known as a overnin- body of the charter school'or"charter school board."-to perform some of its duties vv ith respect to the charter school, please fill in the information requested in the table below. Relative(s) Within the Third Degree of Charter School Board Consanguinity or Affinity(see definition in Member's Name Office Field subsection A) Also Serving on Governing Body of I Charter School i I i I i i i � ; I i i I I j J I 1 I 7 D. If any charter school board member has a relative within the third degree of consanguinity or affinity(see definition in subsection A) N\ho is receiving or will receive any compensation from the charter Bolder or charter school for anv purpose. please fill in the information requested in the table beloly. Charter School Board Member's Name Relative's Name Relative's Employment Position or—] Basis for Compensation i Use the ho.y below ifuciclilionul space is neeclecl E. If a separate goN erningf bode of the charter school exists. please describe the roles and responsibilities that the goveruin(U) bode of the charter holder lias delegated to the ego%erninU bodti of the charter school. If there is onk. one grovernin,_) bode no response is required. - Type Belo-w: F. SLtblllit. ® as Attachment 1,the charter holder's organizational chart that illustrates all oftlte charter holder's operations. inciuding the charter schools organizational structure_ and as Attachment 2. a biographical affidavit for each member of the governing body of the charter holder and of the governing body of the charter school. if applicable. The hio�rrcrphiccrl c�fficicn it ntzrst he completed online,pr'inlc cl crud noltn- ed. The online version of the hiosrrcrphicwl ufficictrh is mwihihle on the on-line resource page. 8 Attachment 1 Westlake Academy Board of Trustees Head of School Services Shared with the Town of Westlake Administrative Town Manager Assistant to Head of School Finance Manager Facilities Manager School Secretai Human Resources Special Services (School CotlnSelor. Special Education) Outsourced Specialists (Occupational. Speech Therapist; Dia 7nostician: PYP(Eleinentarti) MYP (Middle School) Diploma (High School) Coordinator Coordinator Coordinator PYP classroom teachers FMYP classroom teachers Diploma teachers and and specialists and specialists specialists Attachment 1 Attachment 2 TEXAS EDUCATION AGENCY RENEWAL APPLICANT BIOGRAPHICAL AFFIDAVIT (Must complete this verion,print.,notarize, and submit it with your Generation 7 Renewal Application Check- all that apply: [Z Member of the governing board of the charter holder F—]Member of the governing board of the charter school (if a separate secondary board exists) Full Name of Charter Holder (i.e.,nonprofit corporation,institution of higher education,or governmental entity) ITown of Westlake,Texas Full Name of Charter School [Westlake Academy In connection with the above-named organization and charter school renewal application,I make representations and supply information about myself as hereinafter set forth. (Attach addendum or separate sheet if space hereon is insufficient to ansm-'er any questions fully) IF AINTS-kAVER IS "NO" OR"INIONE". SO STATE. 1. Full Name(Initials Not Acceptable):Scott Floyd Bradley 2. Have you ever had your name changed or used another name,-) �Yes ONO If yes,give reason for the change: Did not like given name Maiden Name 0f female): Other names used at any time]Melvin Floyd Bradley(given name) If in addition to being a charter holder or charter school board member, you serve or are employed as an"officer of an open-enrollment charter school" as the term is defined in TEC § 12.1012(6), state your school officer position: lNone 4. If you expect to receive any compensation for any purpose from the charter holder, the charter school, OF a management company of the charter school,provide the information requested below: Amount of annual compensation S10.00 Reason for compensation: N/A Attachment 2A 5. Current Employer:jBradley Luce Bradley, RLLP Occupation:lAttorney 6. List all previous experience with charter schools. Include open-enrollment schools and/or campus or program charters: DATES CHARTER SCHOOL ADDRESS TITLE From Pounding to current date: President of the Board of Directors of Westlake Academy 2600 Ottinger Road Westlake, Texas 76262 -. List all previous experience with any charter school management company: DATES MAnkGEMEN'T CO. ADDRESS TITLE None 8. Is any relative within the third degree of consanguinity(i.e.,your parent,grandparent,great- grandparent, child,grandchild,great-grandchild, sibling, aunt,uncle,niece,nephew;or within the third degree of affinity i .e., your spouse or your spouse's parent,grandparent, great-grandparent, child grandchild,great-grandchild, sibling,aunt, uncle,niece,nephew; also a member of the charter holder governing body or charter school governing body? { Yes �No If Yes. give details N/A 9. Will any relativets j within the third degree of consanguinity or amity{see definitions in 0?&- Lion 7 above be emplo;Jed by or receive any compensation or remuneration from the charter holder or the charter school? QYes (�)No If yes.give details: N/A 3 Attachment 2B 10. Have you ever been convicted of a misdemeanor involving moral turpitude or any felony? Yes &No If yes,give details: AA .Dated and signed this _day of MA4 I herby ceni.fj,under penalty o f perjwy that I am acting on my own behalf and that the"Joregdng statements are true and correct to the best of my knowledge and belief (Sign lure of AfFant VTRIFICAUON State of County of-IA— A On this day, p 7--- &A p) EY (name of want) appeared before me the undersigned notary public and deposed that he/she executed the above instrument and that the statements and answers contained therein are true and correct to the best of his,'her knowledge and belief. Subscribed and sworn to before me this 11nq day of 20 �atr�YP JEAN DWINNELL Notary Public {Nary Public) State of Tex?s q � 5 MvFI� ) 06-16-loos My commission expires C°1 Attachment 2C TEXAS EDUCATION AGENCY RENE�TAL APPLICANT BIOGRAPHICAL AFFIDAVIT (Must complete this verion,print,notarize, and submit it with your Generation 7 Renewal Application Check all that apply: ®Member of the governing board of the charter holder E]Member of the governing board of the charter school(if a separate secondary board exists) Full Name of Charter Holder (i.e.,nonprofit corporation,institution of higher education,or governmental entity) ITown of Westlake,Texas Full Name of Charter School IWestlake Academy In connection with the above-named organization and charter school renewal application,I make representations and supply information about myself as hereinafter set forth. (Attach addendum or separate sheet if space hereon is insufficient to ans"er any questions fully.) IF AINTSWER IS "NO" OR"NONE", SO STATE. I. Full Name(Initials Not Acceptable)]Donald Robert Redding 2. Have you ever had your name changed or used another name? OYes O_No If yes,give reason for the change: Maiden cif femme;: NNarne ,li Other names used at anytime: If in addition to being a charter holder or charter school board member, you serve or are employed as an"officer of an open-enrollment charter school" as the term is defined in TEC § 12.1612(6), state your school officer position: None 4. If you expect to receive any compensation for any purpose from the charter holder,the charter school,or a management company of the charter school,provide the information requested below: Amount of annual compensation S10.00 Reason for compensation: N/A Attachment 2D 55. Current Employer:I Retired Occupation: 6. List all previous experience with charter schools. Include open-enrollment schools and/or campus or program charters: DATES CHARTER SCHOOL ADDRESS TITLE N one -. List all previous experience with any charter school management company: DATES MANAGEMENT CO. ADDRESS TITLE N one S. Is any relative within the third degree of consanguinity(i.e.,your parent,grandparent,great- grandparent, child,grandchild,great-grandchild,sibling. aunt,uncle,niece,nephe«v)or within the third degree of affinity(i.e.,your spouse or your spouse's parent,grandparent, great-grandparent, child grandchild.great-grandchild, sibling, aunt. uncle,niece.nephew) also a member of the charter holder governing body or charter school governing body' Oyes (�)No If yes.trive details: N/A 9. Will any relative(,,-,)within the third degree of consanguinity or affinity(see definitions in Q11estion 7 above)be employed by or receive any compensation or remuneration from the charter holder or the charter school? OYes QNo If yes,give details: NtA Attachment 2E MR Y-15-2006(MON) 15: 38 CITY OF SKREWAY (FRX)907 983 2151 P. 003/003 05/15/2006 16:23 6174300967 TOWN OF WESTLAKE PAGE 04 10. ;;-lave ever be convicted of a misdemeanor involvin�g moral turpitude or any felony? Yes 0 . If yes,give details: day of 20_ab. J herby certify under pa=tjy ofperjwy tluz lam acdng on my own behalf d &t:de?wrzLr are tnx and comet to the tear of my Imam edge atd behqf. (Sigh 4re`EyfAffiarYQ VERMCA'RON �� State of A -- of Ch, this day, Z, (name of affient)awcarcd before me the undersiped notary public and d�ostd tMa he/site cxccjted the above instrument and that the Iatrmcnts and answers conWved thc-rein are ftur--nd cc-rrect to the best ff hislhLr. �rd belief. Subscribed and swum to bcforc me this f day of '4 V 20 (SEAL) My commission expires .NN ti At f 0 Ile 4b 10 STPAS Attachment 2F TEXAS EDUCATION AGENCY RENEWAL APPLICANT BIOGRAPHICAL AFFIDAVIT (Must complete this verion,print,notarize, and submit it with your Generation 7 Renewal Application Check all that apply: W1 Member of the governing board of the charter holder F-1 Member of the governing board of the charter school(if a separate secondary board exists) Full Name of Charter Holder (i.e.,nonprofit corporation,institution of higher education,or governmental entity) ITown of Westlake,Texas Full Name of Charter School 1westiake Academy I In connection with the above-named organization and charter school renewal application,I make representations and supply information about myself as hereinafter set forth. (Attach addendum or separate sheet if space hereon is insufficient to answer any questions fully) IF A.N, 'S-klTR IS "NO" OR"NONE"`,SO STATE. 1. Full 1-Name(Initials Not Acceptable)]Francis William Frey 2. Have you ever had your name changed or used another name? C)Yes (F)N--0 If yes,give reason for the change: ?Maiden N!,%rne(if female):I Other names used at any time: 3. If in addition to being a charter holder or charter school board member-,you ser­a,e or are employed as an"officer of an open-enrollment char-ter school" as the term is defined in TEC § 12.1012(6), state your school officer position: [None 4. If you expect to receive any compensation for any purpose from the charter holder, the charter school, or a management company of the charter school, provide the information requested below: Amount of annual compensation$10.00 Reason for compensation: N/A Attachment 2G 5. Current Employer:I Retired Occupation: 6. List all previous experience with charter schools. Include open-enrollment schools and/or campus or program charters: DATES CHARTER SCHOOL ADDRESS TITLE N one ?. List all previous experience with any charter school management company: DATES MANAGEMEN1T CO. ADDRESS TITLE N one S. Is any relative within the third degree of consanguinity(i.e.,your parent,grandparent,great- grandparent, child, grandchild,great-grandchild, sibling, aunt,uncle,niece,nephew)or within the third degree of affinity(i.e.,your spouse or your spouse's parent,grandparent, great-arandparent, child,grandchild. great-grandchild, sibling, aunt. uncle.niece,nephew,) also a member of the charter holder goveming body or charter school governing body? Oyes (j)No If yes, give details: NIA 9. Z�Till any relative(s)-within the third degree of consanguinity or amity(see de,finitions in Owsrion ?above)be employed by or receive any compensation or remuneration from the charter holder or the charter school? Oyes QNo If yes, give details: NIA Attachment 2H 10. Have you ever been convicted of a misdemeanor involving moral turpitude or any felony? Yes No If yes,give details: .Dated and signed this eR.2 nd dory of 20 0 I hey-by certi f,sander penalty of perjw y that I am acting on my own behalf, and that the foregoing staterrerds m°e true and correct to the best of my dcraowledge and belief. ae& 9 (Sig at r Iant) VERIFICATION State of - County of rf On this day,_ E (name of affiant)appeared before me the undersigned notary public and dep sed that he/she executed the above instrument and that the statements and answers contained therein are true and correct to the best of hisher knowledge and belief. V Subscribed and sworn to before me this 22 day of_ 20 Notary Public j-ta;y Public) State of Texas �1FOF � air C0M ts-2W9 My commission expires (c — Attachment 21 TEXAS EDUCATION AGENCY RENEWAL APPLICANT BIOGRAPHICAL AFFIDAVIT (Must complete this verion,print,notarize, and submit it with your Generation 7 Renewal Application Check all that apply: [71 Member of the governing board of the charter holder 0 Member of the governing board of the charter school(if a separate secondary board exists) Full Name of Charter Holder(i.e.,nonprofit corporation,institution of higher education,or governmental entity) jTown of Westlake,Texas Full Name of Charter School 1Westlake Academy In connection with the above-named organization and charter school renewal application,I make representations and supply information about myself as hereinafter set forth. (Attach addendum or separate sheet if space hereon is insufficient to answer any questions fully) IF A. -',\,SMT-R IS "NO" OR "NONE", SO STATE. 1. Full Warne(Initials Not Acceptable): Delee Brown 11 2. Have you ever had your name changed or used another name? Oyes (DN--o If yes,give reason for the change: Maiden Name Of female): Other names used at any time: 3. If in addition to being a charter holder or charter school board member, you serve or are employed as an"officer of an open-enrollment charter school- as the term is defined in TEC § 12.1012(6), state your school officer position: iNone 4. If you expect to receive any compensation for any purpose from the charter holder, the charter school,or a management company of the charter school,provide the information requested below: Amount of annual compensation S Reason for compensation: NIA Attachment 2J 5. Current Employer:JAII Out Doors Occupation:I Fishing b. List all previous experience with charter schools. Include open-enrollment schools and/or campus or program charters: DATES CHARTER SCHOOL ADDRESS TITLE None %. List all previous experience with any charter school management company: DATES MANAGEMENTT CO. ADDRESS TITLE N one S. Is any relative within the third degree of consanguinity{i.e., your parent,grandparent,great- grandparent, child, grandchild great-grandchild sibling, aunt, uncle,niece,nephew)or within the third degree of affinity (i.e.,your spouse or your spouse's parent,grandparent, great-grandparent, child grandchild.great-grandchild, sibling, aunt.uncle,niece,nephew) also a member of the charter holder governing body or charter school governing body' 0Yes If yes,give details: NIA 9. Will any relative{sj w,ithin the third degree of consanguinity or affinity(see definitions in Question ?a_-hove) be employed by or receive any compensation or remuneration from the charter holder or the charter school? Yes (0-)--No If yes, give details: N/A Attachment 2K 10. Have you ever beenzonvicted of a misdemeanor involving moral turpitude or any felony? YeS Qf4o If yes,give details: Dated and signed this day of 20(SI C- I herby certify under penalty ofperjury,that I am acting on my own behalf, and that the foregoing staterrEds are true and correct to the best of rW knox ledge and belief. t (Signature o giant) VERIFICATION State of Q. County of-arr yl On this day, ur .Brawn {name of affiant) appeared before me the undersigned notary public and deposed that he/she executed the above instrument and that the statements and answers contained therein are true and correct to the best of his,/her knowledge and belief. Subscribed and swam to before me this 2 _ da y of Ma.14 , 20 0 M1 ��taa`'P JEAN DWINNELL E Notary Public w State of Texas otary Public) oF�tE�-"�' § P.06'1e.2009 My commission expires Attachment 2L TEXAS EDUCATION AGENCY RENEW4,L APPLICANT BIOGRAPHICAL AFFIDAVIT (Must complete this verion,print,notarize, and submit it with your Generation 7 Renewal Application Check all that apply: P-1 Member of the governing board of the charter holder Member of the governing board of the charter school(if a separate secondary board exists) Full Name of Charter Holder (i.e.,nonprofit corporation,institution of higher education,or governmental entity) lTmw of Westlake,Texas Full Name of Charter School lWestlake Academy In connection with the above-named organization and charter school renewal application,I make representations and supply information about myself as hereinafter set forth. (Attach addendum or separate sheet if space hereon is insufficient to answer any questions fully.) IF ANSIANTR IS "NO" OR "NONE", SO STATE. I. Full Name(Initials Not Acceptable)]Fred Ehrman Held 1 Have you ever had your name changed or used another name? OYes (�No If yes, give reason for the change: Maiden Name ,,,if Other names used at anytime: 3. If in addition to being a charter holder or charter school board member, you serve or are employed as an"officer of an open-enrollment charter school" as the term is defined in TEC § 12.1612(6), state your school officer position: None n e 4. If you expect to receive any compensation for any purpose from the charter holder.. the charier school, or a management company of the charter school, provide the information requested below-. Amount of annual compensation$10.00 Reason for compensation: NIA Attachment 2M 5. Current Employer: Retired Occupation: 6. List all previous experience with charter schools. Include open-enrollment schools and/or campus or program charters: DATES CHARTER SCHOOL ADDRESS TITLE N one ". List all previous experience with any charter school management company: DATES MANAGEMEN I`CO. ADDRESS TITLE N one 8. Is any relative within the third degree of consanguinity(i.e., your parent,grandparent,great- grandparent, child,grandchild,great-grandchild,sibling, aunt, uncle,niece,nephew)or within the third degree of affinity(i.e.,your spouse or your spouse's parent,grandparent, great-grandparent, child grandchild.great-grandchild, sibling,aunt,uncle. niece_nephm-) also a member of the charter holder governing body or charter school governing body? Oyes �I`o ippf''yes_give details: N/A 9. Will any relative(s)within the third degree of consanguinity or affinity(see definitions in Question 7 above)be employed by or receive any compensation or remuneration from the charter holder or the charter school? OYes (�)_No If yes. give details: NIA Attachment 2N 10. Have you ever been convicted of a misdemeanor involving moral turpitude or any felony? }'Yes v No If yes,give details: Dated and signed this ZZ 4,of 2 0�( I heady certify under penalty ofperjaoy than I'arnlacting on my awn behalf, and that the foregoing staterwnts are trace and correct to the best of my knowledge said belief. / (Signature of giant) 'VERIFICATION State of �j Q S County of ccaA On this day, (name of affiant)appeared before me the undersigned notary public and deposed that he/she executed the above instrument and that the statements and answers contained therein are true and con-ect to the best of his/her knowledge and belief. Subscribed and swom to before me this day of , 20 0 �o,a� Fug JEAN DWINNEu tot Public {Notary Public) State e o of Texas �4 OF SC"� CRY COMW 06-1&2009 My commission expires �. ID Attachment 20 TEXAS EDUCATION AGENCY RENEWAL APPLICANT BIOGRAPHICAL AFFIDAVIT (Must complete this veriom,print,notarize., and submit it with your Generation 7 Renewal Application Check all that apply: [71 Member of the governing board of the charter holder F__j Member of the governing board of the charter school(if a separate secondary board exists) Full Name of Charter Holder (i.e., nonprofit corporation,institution of higher education,or governmental entity) ITown of Westlake,Texas Full Name of Charter School lvvestiake Academy In connection with the above-named organization and charter school renewal application,I make representations and supply information about myself as hereinafter set forth. (Attach addendum or separate sheet if space hereon is insufficient to answer any questions fully.) IF ANSNATR IS 91 O`" OR!NONE-f, SO STATE. I Full Name(1nitialsNTot Acceptable)]Lawrence Alan Corson 2. Have vou e-ver had your name changed 0yes (j)No ged or used another name? If yes,give reason for the change: Maiden Marne(if female): Other names used at any time: If in addition to being a charter holder or charter school board member, you serve or are employed as an"officer of an open-enrollment charter school" as the term is defined in TEC § 12.1012(6), state your school officer position: 4. If you expect to receive any compensation for any purpose from the charter holder_the charter school, or a management company of the charter school, provide the information requested below: Amount of annual compensation$10,00 Reason for compensation: Attachment 2P {_ Current Employer:lHunt Realty Corporation Occupation:lReal Estate b. List all previous experience with charter schools. Include open-enrollment schools and/or campus or program charters: DATES CHARTER SCHOOL ADDRESS TITLE N to 7. List all previous experience with any charter school management company: DATES MANAGEMENT CO. ADDRESS TITLE N IA S. Is any relative within the third degree of consanguinity;i.e.,your parent,grandparent,great- grandparent, child, grandchild,great-grandchild, sibling, aunt,uncle,niece,nephew) or within the third degree of affinity (i.e.. your spouse or your spouse's parent,grandparent, great-grandparent, child grandchild_great-grandchild, sibling,aunt,uncle.niece,nephew) also a member of the charter holder goveming body or charter school governing body? 0 Y e s Q If yes.give details: 9. Mill any relatives}within the third degree of consanguinity or affinity(see definitions in oueslion ?above)be employed by or receive any compensation or remuneration from the charter holder or the charter school? }Yes &No If yes. give details: a Attachment 2Q 1 U. Have you ever been convicted of a misdemeanor involving moral turpitude or any felony? Yes (j)No If yes,give details: Lgted and signed this day Qf '0� 1 herby certify,under penalty©fperjw y tJhcz tarn acting on my own behalf mhd that the foregoing statements aile true and correct to the Ivst of nnv knowledge and belief. J (Signature of giant) ATRIFICAMN State of dI County of r � On this day. ajr',t Lt f t°&ysozj (name of want) appeared before me the undersigned notary public and deposed that he/she executed the above instrument and that the statements and ang ers contained therein are true and correct to the best of his,/her knowledge and belief. Subscribed and sworn to before me this day of �. , I 2r) ¢ ��taFYPI JEAN Dt INNELL 1 _ mf, ` rotary Public Votary Public; State of 1'®xes 1 0F y C ExP 0 9� My commission expires Attachment 2R Section IV. Instr°uetional Facilities 19 Tr1C §100.151 2 7-equines, canong olher things, that a chat-ter hoNcr con7111v with all b7ate a17c1 local 1c1U's aml orcl117c117c'es a131)licohle to the occipatloii w,icl use oflhe fcicll111es 71 occipies, 771Ch1di17g c87V S13eclal Slanclar is applicable 10 the i17S'17'd/c'11017 of Inthlic school slitclents in 1he f icilities. Submit. • as Attachment 3, a certificate of occupancy or equivalent certificate for each site used as an instructional facility: and • as .Attachment 4, a completed Instructional Facilities Forms) for each site that is operated under the charter. The 0171ine Ve1'.SiW7 0f the 117Struc11onal Facilities Forin(s) iS 10c`alecl017 the 017-1117e resource page. fitlrttiiiiltulir Leji 1iictt7k 9 Attachment 3 ft Y^ •.. '-.. ,. � � �' l'^r(� ,`fit' -6 •Y�x{�y{✓/ s�� r , f1 � �� .j •'+tin � � C � r ., J � C 3 •yo Y Y° -� tTL � 4.i r�.. v WOO Quo 'e. low,I Am TV tj 3y ••\ N : A ^�.ti�� LP ` � jIf y � ' Vj I�rf � sy v 8� to � I Mal '� �� •� •� Ps 1 � "� mss'` } , sit x .Y t. s � wd B HAM j n ,^ "Z � Attachment 3 Attachment 4 Instructional Facilities Form Must complete this version, print, and submit it with your Gen. 7 Renewal Application Please provide the following information concerning the local agency that issues certificates of occupancy, or their equivalent, in the jurisdiction in which each campuses is located. Please attach one form per campus. Campus Name'. Westlake Academy Nine-Digit Campus Number. 220x10001 (9 digit number, without dashes) Address of Campus.- 2660-Ottinger Rd.,Westlake,Texas 76262 Name of Local Agency:LTown of Westlake Name of Contact Person at Local Agency.- Jim Taylor-Building Inspector Telephone No. for Contact Person at Local Agency:F8177 -F4790 - 5718 Address of Local Agency-12650 Otnger Rd., Westlake,Texas 76262 List any other pertinent information. Attachment 4 Section V. Teacher Qualifications The requirements for certain teachers changed in 2002 Nv ith the passage of the No Child Left Behind Act(NCLB). The NCLB requires charter school teachers assigned to teach core academic subject areas (i.e., English,reading or language arts, mathematics. science" foreign lan,ouages. civics and �gyo�ernment. economics.arts, history.and geo�?raph��) to be "highly qualified.'" To be"highly qualified,"a teacher assigned to teach a core academic subject area must hold a bachelor's degree and demonstrate competency in each area of assignment. (For more information about required teacher qualifications, please see the publications of the NCLB Bullelin, available via the on-line resource page). Charter school teachers assigned to teach subjects that are not considered core academic subject areas under the NCLB must meet the state law requirement of a high school diploma. Furthermore, state law and rule require charter school teachers assigned to teach special education. bilimgcual education, and English as a second language to be certified. Mane charter schools require their teachers to have additional qualifications beyond the minimum requirements of federal and/or state la~N. A. In the space below.please set forth the qualifications that the charter school requires for teachers assigned to teach core academic subject areas (i.e.. English. reading or language arts. mathematics. science. foreign languages. ciy ics and government. economics. arts. history. and geography). Type Beloit: All teachin-1 staff will possess a minilmlm of a bachelor's degyree and \\ill be encouraged to seek Texas Teachers's Certification during employment. Those teachers assigned to teach core academic subject areas v�ill be expected to have a university deLree M that subject area or possess a teacbin—, certificate to teach that subject. ` B. In the space hel<����. please set forth the qualifications that the charter school requires for teachers assigned to teach SLINects to:t 'ire not considered core acade is StibleCi al"eaJ Llntlet' the NCLB. TN pe Below: All teaching Staff %\ill poSSeSS a Mit:iMILIM OI a bnChe1Or's ijeLI'Ce a!ICI \\Ill be CiICOUra`.ted 10 Leek Texas Teachers Certiticat l(111 durin�>�n�plo_�mint. I I i 10 C. In the space below.please set forth the qualifications that the charter school requites for teachers assigned to teach special education. Type Below: Teachers assigned to teach Special Education must hold degrees and certification for Special Education. D. In the space below. please set forth the qualifications that the charter school requires for teachers assigned to teach biiin2ual education and/or Eno lisp as a second lanhruage. Type Below Teachers assi,ned to teach bilin`ual and'or ESL must have the necessarti certification to do so. i lntenliontilll'Lef Blank 11 Section VI. Compliance with Complaint Procedures The charter holder board chair must sign below to acknowledge that: (1) the governing body(ies)and school officers are aware that 19 TAC§100.1033(c)(6)(C)(i) states that the governing body of a charter holder shall not dele-ate final authority to hear or decide employee grievances,citizen complaints, or parental concerns; and (2) the governing body of the charter holder is in compliance with the above requirement. ------J1� --- -- ------------------- Signature of Charter Hold F3oard Chair Date (t�aa�st s•i�a ifa blare ifa � InIe rtioralh-Left Blank 12 Section VII. Admissions Policy A. Specify the period during ��hicll applications for ad mission are accepted. TEC', §12.117, requires 117cri a charier sclioul esluhlish a reusonuhle ulydiculion deuclline•fnr the submission of ulyViculions,for uclntission. Beginning) of Period End of Period ongoing (N1()nth.'1h\) {t]onth.'Daq B. If the school admits students by lottery sullen the number of admissions applications received exceeds the number-of available spaces, describe the procedures follosx ed in conducting the lottery. Type Below: See attached page for Lotted Procedure C. If the school utilizes a lottery -,\lien oversubscribed. are any categories of applicants exempted from the totter}? Check one:❑ Yes ❑ No ❑ 'Not applicable (because lotteries are not utilized) If"Yes" ssas indicated in C above. state the categories of applicants that are exempted. Ti pe Belo-vs: -Residents of the Tovvn of Westlake Academy -Siblings of present Westlake Aeadem_s students -Children or Emplo\ees -Children arnci Grancicllildren of FoundC1-S L� I D. Ifthe school utilizes a lotted vs hell rnersubscribed. specitl tilt approximate date on hich a totter} ssIII be conduCted. Approximate Date of Lottery 1 I 02110 (Mond) Din) E. If the school does not utilize a lotted vvlien oversubscribed. but rather fills the available positions in the order in which applications were received before the expiration of the application deadline(i.e., a "first-come, first-served-admission process). describe the manner in tis hieh the school notifies the community of the opportunity to apply for admission. TE('. §12.117, requires U churler school thu1 uses U first-Colne,.fir's1-se rveLl U[/III 7sSi01T 1)1-0(-e,SS 1117e11 O1'erSZibsY 1`TheC1101)tihli.S1717 nolice 717 U 17e1f-.41)6ll)e7-Qf('Merul ch-calution not luter 11 an the Se 1'e171h(1qv before the(1l)1)IiCU1X)17 clemlline. Type Below: l 13 hotter! Procedure A public lottery advertised in local newspapers was held for all grades before the first class year. All family names were embossed on balls which were placed in a hopper. Names were drawn at random until all balls were withdrawn. Positions were filled in the order drawn. As positions filled. the remaining names were placed in order on the wait list. Applicants applying thereafter were placed at the end of the wait list on a "first come-first served" basis. Following the first rear. the lottery has been conducted only for Kindergarten, utilizing the same method. Page 13 cunt. F. Describe the information that an applicant must provide in order to be considered for admission. -gj)pliccrrlls ll7u) not he 7-C'clll77-ed to pi-o17de eolVeS o�IPU17SC'7'7j)1S ol-othe7'acC1C1'C'mic 7-eeolYlS until Uftel'the)-(we Offered(IdllnS.S7o77 U77d CITe elll'olllNy. Fw-lhel-17707V, U SIMIC171 I17c117 1701 he preeludediton7 CIII-011il7g due to the c'huner school's 'e 10 7-ec-eive i77 1-177u1ioll requh-ecl.f)7'e177'011177e7II(7.0177 the sllldenl's I)c77Y171 01-g1t(H-dicnl 07-I)7'erious school. See TEC, '?5.003. Type Below: The waitin- list;lottery application is the same application that N+e use for enrollment:however only the top two sections are required for the application process. Information required: name. SS".age. grade level, birth date. sex. district student is zoned for and ,uardian contact. G. The charter holder certifies that the non-discrimination statement required by TEC. ti 12.11 1(a)(6) is printed in the schools admission policy. TEC. §12.111(6) 7-equh-es Ihut a eha77e1' c7 school's In7issi077SholIC:)'117CIZiele U slate171en1Ihat the school Will 1701(ILSC1 iMilMile 171(0II7iS,S7o71S htlS'e(l011 gelldel', 17011on(1101.1O111, ethniciI)'. I-('h('),lon, cllsubil 1)', ucudeMiC. UI'IiSIi(-, ()I- uthletic clhilily. or the district the child would other-wise ullencl Check.one: ❑Yes ❑ No H. Does the admissions policy either require or permit the school to exclude from admission all students \\ith documented 1istories of a criminal offense, a jtnenile court adjudication. or discipline problems under TEC Chapter 37. Subchapter A as authorized b%I TEC. § 121.1 1 1(a)(6)? Check one: ® Yes (The school excludes such students or reserves the right to exclude such students from admissions.) ❑ No (Tile school does not deny adillission to such students based oil their documented histories of misconduct.) 1. Submit. * as Attachment 5. a current cope of the admissions police that incorporates the information provided in tl;e above anal;er; to questions A throuuh H and an\ other relevant information: as Attach ment 6, a blank copy of tale Current adimissmns application (i.e.. flic inforiilatiOn relIllested 1l lien the student seeks admission): and as Attachment 7_a blank coPy of the current enrollment forms) (i.e.. the information reyuircd once an applicant hay hrrn offered admission and is registering for enrollment). 1111011l01l(I1N Left Blank 14 Attachment 5 Waiting List means a list of applicants desiring admission -when space becomes available. Waiting List applicants are admitted in the order they appear. Eli Ig-bilih: -`s l eligible Primary Geographic Boundary Students and Initial Primary Geographic Boundary Family students kill be admitted to the school. The burden for proving eligibilin_ rests with the family of the applicant for admission. Legal verification of residency may be required at any time. I`or ehgibilin- purposes, residency of the child of divorced parents is considered to be that of the sole many ring eonselz ator or the joint managing conserx•ator with whom the student lives for the majority-of the school week. Transfer Students are eligible for admission based on available space. Transfer Students mar be admitted after all eligible Primary Geographic Boundary- Students, Initial Primary Geographic Boundary Family students, and Siblings of students enrolled u1 Westlake Academy,are admitted. If more Transfer Students seek enrollment than space is available, then a Lotten- will determine admission order of the Transfer Students. No Lorten-yl ill be conducted for any(Trade that has a \Vaiting List.Transfer Students desiring admission after the Lotten- has been conducted grill be placed at the bottom of the Waiting List and may be admirred as space becomes available. The _\cademr resen-es the right to deny admission to any student regardless of residence. Westlake _leadenly gill not enroll any student-who has been subject to expulsion or who is awaiting cspulsion from any educational ills dtltion. _ldnlission rules may be changed or modified at any time by the Board of Directors of the Westlake academy,or as may be required by applicable laws,rules or regulations. .application Procedures: All parents -wishing to enroll their students in the \\estlake _\eadeiny must coinplete an _Application for Enrollnient. _applications are available at the \\estlakc academy, 26(1() Ottin_'rer Pond. Westlake. 'Texas. between the hours of') a.m. and ; n.*._l., Monday throlhrh i rida�. _ypplicatians should be picked up in pers,)n and returned in person. I'arenis of enrolled students niiisr cnmplere a new apl)llcatlon forth cacll vc:1r ill nrdi'r to assurc thOt schol;l files .re i:cctlr.lre ::I:Id iIh u) ditty. !=>dsific:uion of infonnaiiou provided Or, the ;Spp1 ) oUld Ur IPmedl:lte ZnC perill;incIlt rnlyal fro)-in the school.IUrIn I� > . l he _ACitdCllly II1ay reClLiest a pre- Cf tlilsFlon 121 rCn 1CR to CuSL1l-C flat afl Tanlllle< ?.rC 41v[' r' tt4 the school's policies, procedures and philosophy _1 class roster .,ill be puhlished 1)" `March I" (d v(:ar. An applicant appearinc, on the roster will be admitted unless he;'she }ails to meet chgibilin_-requirements on the date classes be nt.4 So.l)TL 11)1)Cr,206 April,20H5 6 Attachment 5B ADMISSION The Westlake Academy is an open-enrollment Charter School operating under a Charter wwarded to the Town of Westlake by the Texas State Board of Education,v-ith oversight bN the Texas Education Agency (TEA), Charter School Division. An open-enrollment Charter School may not deny admission to a student based on sex,national origin,ethnicity-,religion, disabihn-, academic ability-,artistic ability, athletic abilin-, or based on the school district that the child would otherwise attend. The _academy is committed to obtaining and maintaitling a diversified student and staff population.' Definitions: '` Initial Priman- Geographic Boundary Family is a family that resided in Westlake and whose student was enrolled in Westlake Academy on )une ?()ti{ or was cnrc>lled in Kindergarten on\la\.S(l,2005. Lotten- means a public]\. posted and publich conducted random drawing from name~ of qualified Transfer Students desiring admission to the\Vestlake.�cadctny. Lotten- Application Deadline is the last day of lanuan- of the calendar year of desired rnm-. Primary Geographic Boundary Student means a child of school age: (a) living \with his;'her parent or legal guardian -a-ho is a resident of \;-cstlakc, or 1) -\vhose parent or grandparent is listed i the TE-\ Charter -\pplication as a F=ounder or Officer of the Westlake _\cadet n-, or (c) whose parent or legal guardian is employed by the To-,vn of Westlake or the\\estlake.\cademy. lr. c rder to be a;nsidercd a Pritn:u� C1cographic Boundar titudent. parents or legal. ill;?rdlatls \fill, -1-111 the student res?ics must reside in N Cstllke o: have on ii1c with the Tow,1 of 111;cstlakc an appro�ed rest 3ciltial F3uildimu Pcrmit prier m ,�cPrcmixr 1 of the school vc� lz in Nvhich admission is sought. Eli�nbilin for students ,ldnlittcj antler this prof isinn \c ill be Withdra-,"n if, in the opiihon of the (.'I:U, there is no satisfactoiA dcmon'�tr:i.i')n t7f intent to 1'--u ... A\.'titlahC bv Sibling ineans the brother or sister of a student enrolled in \Westlake _Acadcmy. This definition includes adopted brothers and 'or sisrers. and children residinc, in the same household -,vith their parent(s) or legal guardian;sj. Transfer Student means any child of school a e that dons not meet the definition of Priman- Geographic Boundary Student. �" ti�ptcmhcc'�If li 5 Attachment 5A Admission Order: FIRST ADMITTED Primary Geographic Boundary Students and Initial Primary Geographic Boundary Family Students SECOND ADMITTED BASED ON AVAILABLE SPACE Siblings 01"students enrolled in Westlake Academy. THIRD ADMITTED BASED ON AVAILABLE SPACE Transfer Students No Student will be admitted unless the Westlake Academy has received a completed application. Applications must be resubmitted each year to enable the Westlake Academe to maintain accurate and Current information.` Siblings The Sibling OF an enrolled student imm- be admitted as space becomes available according to the order in vi-hich the first contimioUsl\--enrollcd sibling -,,-is idmirred to the Wcstlnke� Year to Year Admission Once admitted to the school, all eti nble student lorrin llc,-111,,- clu',ilifics for enrollment in subsequent Ycan, vathout being subject to n I.,orrcn-. If, howcvcr, n student leavet, tile school, then that student must reapply and,,vifl be irlox-cd to the bottom Of the V',,n6ng List. Wcsthlku Acadumv will not enroll -1m, student who has been subject to expulsion or whO 1s 2\vait no-C-xpulsiorf from arly if-,I Primary (;eof'rlPhlc 13DUIIC121�_ �[UdCflt (Or the parents or 'uardians vvlth -\vIlom lic'she ;i 711UYlbui, 01 ;Ila 11"irl":11 P–M217., Finilh, d(..s vd 1 7 renuly es Ills 11k:r from Wcsihikc, then Tllar student ll(•vcrrhd(-sS will be t,11(,J*b]C for hcr ("moll—c"Ir -f )1, -11", cilirc tll:, Zinc (if, ii n— has cnn-irilcte" t 11C.-ist 17vc61c,1dcri-,'c vt-arz ii1 Wcstli­,kc Ac;idc,­f,.,-. sttldent f YoNx n o1_\X'csr1iik(: orTustlilk(: Acildumv cmplm-cc is(lip ibIc for yCar-to-v u;Ir admission so lorfg;is his, her parent or guardian remains cirlp1mcd In- the'1'0-,\-,, of\Vcst Or Westlake _lc;idem\-. A srudunr of a To,,vrl of\\cstlnkc or Wcsthlkc Acndcmv einplOi-ce whose ernplov-mem terminates before the employee h-,is, completed fivc co,16,111(11s .rats s Of service "rill no lorl�cr be eligible for admission and \vIll be moved to the bottom of the V'a 16 n""List. J7&ccpi as pr()vldcd ,ibovc, a srudclir will be allowed to rummil 113 the school onlN. until the end of the "CliltsTer in-,vh1ch lils./her parents'or gm-irdian's residurfcv_or crnplov-merft (,-is the case be)is tern'llinated. 7 Attachment 5C If i-wo or i-nnre siblings tic for ;III loblc p')SIl o-n by virnic of ilic'� po,-,'iion� oa the-1 1 1 1 . i u pi ions I list:, the order of admission will be ClCtermilled by I of I Cry- Attachment 5D Attachment 6 Westlake Academy Student Application PLEASE TYPE OR MUNT Student Social Sectarity APP.Date / j24� �' 1 Sept. 1, 2006 First Middle N e Name Name Date of Birth Flo /Day /Year Age Sex Ise / F Place of Birth (City, State,Country) Primary Language Additional Languages School student is zoned to attend according to Last School Attended address Primary Guardian(s) Relationship (Witte Student Lives) Street Address City, State q TX Zip Country Day Phone Evening Phone CeU/Pager E-mail Address Fax Otber Guardian Relationship Street Address City,State s Zip Country Day Phone Evening Phone Cell/Pager E-mail Address Fax MM Contest Relationship (Relativel eighbor) Street Address City,State s TX Zip Country Day Phone Evening Phone Cell/Pager E-mail address Fax Attachment 6A Westlake Academy Student Application (Page 2) Previous Schools Attended District School City/ST Yrs Attended Grades Were you ever Attended retained? If so, what Grade — —_ c J. +.... .ta .�.%�lG c� t ;,a: I/We understand that Westlake Academy,as a"school of choice", is designed to provide an alternative learning Initial to Accept environment separate from other schools or school districts. I understand that Westlake Academy provides a creative but challenging educational environment designed for students who are willing to become serious leaniers. I/We understand that by enrolling my child in Westlake Academy I am agreeing to abide by and support the Initial to Accept Westlake Academy community,procedures and policies. I/We understand that Westlake Academy reserves the right to dismiss my child from the school for reasons listed and Initial to Accept explained in the Code of Conduct. I/We understand that Westlake Academy reserves the right to send my child home for a variety of reasons, including Initial to Accept but not limited to: failing to be in an appropriate school uniform and or failing to act in accordance with the school's code of conduct. Absences due to being sent home are unexcused.meaning students are not guaranteed credit for missed assignments and the absences count toy}ard the State's 90%Attendance Rule. I/We understand that I am a valued member of the Westlake Academy community and that my active participation Initial to Accept and involvement is openly encouraged and expected. (Please note that choosing Westlake Academy means a commitment on your part to the Westlake Academy Community.) i/We understand that I am expected to support the reasonable and professional decisions of the Westlake Acadern3' initial to Accept faculty, staff and administration. If I have a grievance or complaint, I understand that I am expected to follow the school's protocol for resolving it,and I will try to resolve things in a timely, friendly and cooperative manner. I/We understand that Westlake Academy is an open-enrollment charter school and may not deny admission to a Initial to Accept student based on sex, national origin,ethnicity, religion,disability,academic ability,artistic ability,athletic ability,or based on the school district that the child would otherwise attend. I/We understand that Westlake Academy is a school of choice. Therefore, 1 know that I am under no obligation to Initial to Accept keep my child enrolled at V'estlake Academy if I am dissatisfied with services,policies or procedures provided b} the school. f Does Student have a documented history of criminal offense,a juvenile court adjudication or discipline problems under Subchapter A,Chapter 37 of the Texas Public Education Code, Yes / No Relating to Discipline;La",and Order, including but not limited to suspension from school, school reassignment,or any other school related or legal disciplinary action? By signing this enrollment form,you affirm that the information provided on this form is true and correct. False information provided on this enrollment form can result in Signature of Legal Guardian Mead of School Approval dismissal from Westlake Academy. Date gate Attachment 5B Westlake Academy Home Language u e PLEASE TYPE OR PRINT RZ g Student Social Security# _ App,Date / I2046 Grade Level Sept. 1,2006 First Middle Last Name Name Name 'hat Language is spoken in N�%at Language does the Student the Horne Most of the Time? Speak Most of the Time? By signing you affirm that the information provided on this form is true and correct. Signature of Legal Guardian Date Attachment 6C Westlake Academy Student Records Release PLEASE TYPE OR PRINT M20 M- 1 o s� 8 e i l St udent Social Security rst Middle Last Name Dame Name To Whom It May Concern: My child, identified above, has submitted an enrollment application to The Westlake Academy Charter School for the school year . By signing this form, I give the parental consent necessary for (Previous School District) to supply copies of e following information related to my child: • All discipline Records • All T'AAS,IT'SBS and any other similar other test scores • The student's transcript • The student's report cards The student's shot records Any psychological educational assessment ® Any emotional educational assessment ® Any comprehensive individual assessments Any special education evaluations or assessments Any individual education plans Any behavior management plan Thank you for your assistance. Signature of Legal Guardian Date Recipient:Please send this documentation at your Attn: Westlake Academy Registrar earliest convenience to the following school address. 2600 ttingec Rd. Westlake,'Texas 76262 817.490.5757 For Office Use Only: Date application recv'd by Date application entered by Date faxed for school records by Attachment 61) Attachment 7 ENROLLMENT PACKET FOR YOURNEW W- -T-11, ST-,UDENT TO Westlake Acad-emy Please return a copy of the following with your registration packet: IMMUNIZATION RECORDS BIRTH CERTIFICATE STUDENT'S SOCIAL SECURITY CARD PARENT DRIVER'S LICENSE (We can make copies of these items at the school.) Attachment 7A Westlake Academy Student Records Release PLEASE T}PE OR PRAT 6 Ffi "A"E wR ,. E r,• �._ Student Social Security# First Middle Last Name I Name Name To Whore It May Concern: My child, identified above, has submitted an enrollment application to The Westlake Academy Charter School for the school year By signing this form, I give the parental consent necessary for {Previous School District} to Supply copies of the following information related to my child: • All discipline Records • All TAAS. ITSBS and any other similar other test scores • The student's transcript • The student's report cards • The student's shot records • Any psychological educational assessment • Any emotional educational assessment • Any comprehensive individual assessments Any special education evaluations or assessments Any individual education plans 2 Any behavior management plan Thank you for your assistance. Si<anature of Legal Guardian Date Recipient: Please send this documentation at your Attn: Westlake Academy Registrar earliest convenience to the following school address: 2600 ®ttinget Rd. Westlake, Texas 76262 817.490.5757 For Office Use Only: Date application recv'd by Date application entered by Date faxed for school records by Attachment 713 Westlake Academy Student Application PLEASE nPEORPRIAT Iii i iii 10-M! •�6P�pk9:�Hu.. i�9l.��&�`.g-IDB .. � 4a4AQ'° m Grade Level Sept. 1, Student Social Security - APP.Date / /2006 2006 First Middl e Last Name Name Name Date of Birth tvlo /Day /fear Age Sex M / F Place of Birth (City, State,Country) Primary Language Additional Languages School student is zoned to attend according to Last School Attended address Primary Guardians) Relationship (With M'tlom Student[Li®•a) Street Address City, State 9 Tx Zip Country Day Phone Evening Phone Celt/Pager E-mail Address Fax Other Guardian Relationship Street Address City, State ' Zip Country Day Phone Evening Phone Cell/Pager E-mail Address Fax Contact Relationship (Relative,'I�Ieighbor) Street Address City, State ' TX Zip Country Day Phone Evening Phone Cell/Pager E-mail Address Fax Attachment X Westlake Academy Student Application C�§1 trK14 Previous Schools Attended District School City/ST Yrs Attended Grades Were you ever Attended retained? If so, what Grade e� � @ i � a 1r t a ��� r «.,3« ro ��u�$ � ."� -5-.,' ��a'.t's�-g^.;•` �'��'d -n�s� � � I/We understand that Vestlake Academy, as a"school of choice", is designed to provide an alternative learning Initial to Accept environment separate from other schools or school districts. 1 understand that Westlake Academy provides a creative but challengin educational environment designed for students who are willin to become serio�a�tearrers. I/We understand that by enrolling my child in Westlake Academy 1 am agreeing to abide by and support the Initial to Accept Westlake Academy community,procedures and policies. I/We understand that Westlake Academy reserves the right to dismiss my child from the school for reasons listed and Initial to Accept explained in the Code of Conduct. I/We understand that Westlake Academy reserves the right to send my child home for a variety of reasons, including Initial to Accept but not limited to: failing to be in an appropriate school uniform and or failing to act in accordance with the school's code of conduct. Absences due to being sent home are unexcused, meaning students are not guaranteed credit for missed assignments and the absences count toward the State's 90%Attendance Rule. 1;We understand that I am a valued member of the Westlake Academy community and that my active participation initial to Accept and involvement is openly encouraged and expected. (Please note that choosing Westlake Academy means a commitment on your part to the Westlake Academy Community-.) I/We understand that I am expected to support the reasonable and professional decisions of the Westlake Academy Initial to Accept faculty,staff and administration. If I have a grievance or complaint, I understand that I am expected to follow the school's protocol for resolving it,and I will try to resolve things in a timely, friendly and cooperative manner. I/We understand that Westlake Academy is an open-enrollment charter school and may not deny admission to a Initial to Accept student based on sex,national origin,ethnicity, religion,disability,academic ability,artistic ability,athletic ability,or based on the school district that the child would otherwise attend. I/We understand that Westlake Academy is a school of choice. Therefore, I know that I am under no obligation to Initial to Accept keep my child enrolled at Westlake Academy if I am dissatisfied with services,policies or procedures provided by the school. `"��• ✓ wax- ro.K�4:3p'. L�FlYi,,'3�$ .b�SiT�"@+�'�'�.3•su�"+ayr� �i� b+a'wc^�' ^.��y2i?,�"a`1�t`g r. � �°A:y^�'��e�'ay�., s,* : L.q, �' =. Does Student have a documented history of criminal offense,a juvenile court adjudication or discipline problems under Subchapter A,Chapter 37 of the Texas Public Education Code, Relating to ®iscipline;L.aw and®rder, including but not limited to suspension from school, ��' � �� school reassi nment,or an other school related or legal disci line action? By signing this enrollment form,you affirm that the information provided on this form is true and correct. False information provided on this enrollment form can result in Signature of Legal Guardian C.E.O.Approval dismissal from Westlake Academy. Date Date Attachment 7D Westlake Academy Home Language Survey PLE9SE TYPE OR PRI NT Student Social Security# _ _ App.Date f /2Q� Grade Level Sept. t,2006 First Middle Last Name Name Name What Language is spoken in What Language does the Student the ]--tome Most of the Time? Speak Most of the Time? By signing you affirm that the information provided on this form is true and correct. Signature of Legal Guardian Date Attaclunent 7E GRADE Dear Parent/Guardian: E-mail and Fax are becoming an increasingly popular and effective way for parents to communicate with school personnel. For your convenience, Westlake Academy has published the school Fax number and the E-mail address on the school's web site at However, in order to comply ,with federal reoU121ions regarding the confidentiality of personally identifiable student records, parents insist sign the consent form below before 2 school employee Can correspond via E-mail or F21 re-21-ding student's beh2l•i0r, 2C2dernic progress, disability and/or medical condition. Although the risk of obsen'2tion by an outside p2rTV May be minimal,the district must have this signed consent form in order 10 pat-tiCip2te in these types of E-mail and Fax correspondences. Thank you for your assistance. WESTLAKE ACADEMY Parental/Guardian E-mail / Fax Consent Form give/do not give(please circle one) (full name Ofp2rent/guardi2n) permission for the following student information about my child/ren: to be sent tome electronically by the staff ofNVestl2K-e .academy. Please check those that are Permissible to E-mail or Fax. academic progress/grades behavior medical condition/disability other(specify below) I understand that the transmittal or this in-iferial may not be available by entirely secure methods and may be capable of obseii-2tion, intel•ception, or manitorinc, by others. Furlhermore,l understand the school cannot guarantee the records will be received only by the requester at the E-mail address provided. I request the student information about mychild be sent to the following: E-mail address (please print CLEARLY) Fax Parent/Guardian Signature Date Signed This consent is •nilid throti2h the end of the school ve2 r.unless otherwise noted. Attachment 7F TICE Photograph/Video/Sound Release 06-07 Westlake Academy, Westlake Academy Foundation, and its representatives ("W.A.") on occasion take photographs of students and school events for use in print and electronic publications. i.e., yearbook, promotional materials, brochures" videos. school web-site. newsletters. etc. This serves as notice of W.A's intent to do so and as a release to W.A. of permission to use such images as it deems fit. However. if you should object to the use of your child's photograph or name in any medium, you have the right to withhold its release by returning the completed form below to the School Office. Barbara Brizuela Head of School Photobraph/Video/Sound Release Form ❑ 1 herebt- �(irant Westlake Academy. Westlake Academy Foundation. and their respective representatives permission to publish the image/name(s) of my child(ren). ❑ 1 refuse to Dave the image,/name(s) of my children) published. ParentiGuardian: Date: [printed name] Name of child: Grade: Name of child: Grade: Name of child: Grade: Name of child: Grade: Address: City: State Zip Phone: E-mail: [Parent!Guardian Signature] This consent is valid throuffh the end of the school Near,unless otherwise noted Attachment 7G History of Chickenpox Illness Student: Date of Birth: This is to verify that the student named above had chickenpox illness on or about and does not need the varicella vaccine® Parent signature: Date: Attachment 7H Westlake Academy 2600 Ottfinger Road Westlake, Texas 76262 Child's Name: Date: Grade: SPEC LkL SERVICES FORM (if none,please mark through, sign, and return) My child has received the following services: Resource Speech Other Special Education Services Counseling ESL Bilingual Title I Dyslexia Chapter I Pre/K Emrly Childhood Other specif},: I give any perinission to have my child placed in the appropriate Special Education class prior to the Transfer ARD, as verified by the students previous school. Parent Signature: Date: TO BE FILLED IN BY THE AD�IrNTISTPUTION Verification of Special Education services: Date: Person contacted: Position: Eligible for: Subject or subjects and time: Attachment 71 WEST .AIDE ACADEMY ETHNICITY FORM Student Record Information Student Nane: Westlake Academy is required by state law to register our students %vith their ethnicity indicated. Please circle the appropriate ethnic category=for your student. Thank you. While,not of Hispanic Origin Asian or Pacific Islander Hispanic Native American/Alaskan Nati�-e African American, not of Hispanic Origin Attachment 7J Westl2ke Academy Enrollment Record PARENTS: PLEASE PRINT IN PENCIL AND COh4PLETE BOTH SIDES Student Name: Last Name First MI Nickname Generation Code(Jr.,11,111 etc.): Sex: Grade: Social Security #: (Office Only:Piems alternate ID 9): Copy of SS card provideO Y® N ® Copy of Birth Certificate?Y N ® Copy of Immunizatiomsi Y— N Date of Birth: Birthplace: ciry State cc>&ny Home Phone — 0 UNLISTED Circle the grades your child has attended in the United States PK3 PK4 K 1 2 3 4 5 6 7 8 910 11 12 Student resides with: 0 father 0 Mother 0 Legal 0 Guardian ❑ Other: Home address: City: Zip Code: Father/Guardians Name: Legal Guardia Y® N Employer: Work Phone: Pager #: Cell Phone 4: Other 9: Mother/Guardians Name: Legal GuardiaL nY® N EMP103'CT: Work Phone: Pager 4: Cell Phone#: Other 9: School District student is zoned for: School student is zoned for Last school attended: Date: Grades: Address: Phone#® City State Zip (0 Ali see NO'rely: Last report urd/W ith dra-,val received Date records requested: Attachment 7K Name of siblings in family: School Attending Any person who knowingly falsifies information on a form required for the enrollment of a student in the Westlake Academy commits an offense under section 37.10 of the Texas Penal Code, which offense is a class A misdemeanor unless the person's intent is to defraud or harm another, in which event the offense is a felony of the th ird degree. My signature below confirms that I have read and understand the above information and accept the responsibility for any false information concerning the enrollment of the student. Parent/Guardian Signature: Attachment 7L WESTLAKE A C A D E M Y STATE OF TEXAS § § AFFIDAVIT OF SCHOOL VOLUNTEER COUNTY OF TARRANT § Before me, the undersigned notary, on this day personally appeared , a person whose identity is proved to me through (describe the identifying document). After I administered an oath to him and upon his oath he said: 1 My name is 1 am over 18 years of age, of sound mind, and capable of making this affidavit. The identifying document listed above is correct and authentic. The facts stated in this affidavit are within my personal knowledge and are true and correct. Z 1 have voluntarily authorized a check of my criminal background history by the Town of Westlake and the Westlake Academy. 3, 1 authorize the Town of Westlake and the Westlake Academy to terminate my status as a volunteer at any time and with or without cause. 4. 1 agree to save, indemnify, release, and hold harmless the Town of Westlake and The Westlake Academy, their officers, employees, representatives, agents, and attorneys from and against any and all loss, claim, causes of action, including any loss or claim of loss for bodily injury' or death. It is the intent and agreement of the affiant that this indemnity include acts, damages, or loss caused by the negligence, or alleged negligence. 5. 1 do not now and I have not at any time, either as an adult or as a juvenile, been charged, investigated, convicted, terminated, forced to resign, treated for, institutionalized, sued, settled a claim before suit, lost a state license, been refused a volunteer position, violated a court order, had a report of chid abuse or neglect made and substantiated against me, or have any pending criminal charges against me in this or any other jurisdiction due to any conduct, matter, or thing (irrespective of formal name thereof) constituting, relating to, or involving (whether under criminal or civil law of any jurisdiction) a minor, juvenile, child, lewdness, indecency, a felony, obscenity, pornography, sexual assault, rape, or incest. Attachment 7M Signed: Print Name: Date SWORN TO AND SUBSCRIBED before me, the undersigned notary, on this day of Notary Public in and for the State of Texas Address: Driver's License Number and State: Date of Birt1i: _ SS": K\Boyie-Lowry^,VVest Lake\wl-affidvit\r✓I-affidavit-school volunteer-simple form.doc Attachment 7N Page 8 WESTLAKE A C A D E M Y Volunteer Program Confidentiality Statement I understand and agree that in the performance of my duties as a volunteer in the Westlike Academy Volunteer Program, I must hold in strictest confidence any observations I may make or hear regarding students, students' families, school staff or school business. I understand that intentional or involuntary violation of confidentiality may result in disciplinary action including termination by the Westlake Academy Volunteer Program and/or legal action I'y others (i.e., students, families of students, school staff, school administration, etc.) Volunteer Signature Date Please Print Your Name Attachment 70 E_ AGREEMENT OF SUPPORT:A1 Parent /Guardian AS 2 parent/ guardian of child attending Westlake Academy,I agree to Support the school in carrying out policies and procedures as indicated in the Parent/Student Handbook. I recognize that Westlake Academy is a public Charter School and I have voluntarily chosen to enroll. Student Name In return for supporting the school policies and procedures, I expect the faculty and stiff of Westlake Academy to provide mi. childuith the n-pe of education stated and implied in the Parent/Srudent Handbook. Name of Parent/ Guardian Relationship to Student Signature of Parent/ Guardian Date Student I nrn am-are that Westlake Academy is 2 school of choice. After talking with mi- parents/gu2rdi2ns, I have chosen to attend Westlake Academy. As a student at Westlake Academy, I agree to accept responsibility for following the 1 9 policies and procedures as described in the Parent/Student Handbook. Student's Sign2rure: Date Attachment 7P Section VIII. Special Education Assurances The charter holder certifies that it has policies and procedures in place that ensure implementation of all federal |uxs and regulations., Texas |uv/s, State Board of Education (SB(}E) and commissioner rules related to students with disabil ities and further certifies that any future amendments tothe |u*s, re-u)atioua, and rules will be incorporated and implemented. ^ ______- _���-����—_—_______ �/8nu1ure�of��Uu�cct|o|d ourdChuir Du1c (xno/x� / b/ �/nx �7 � I 'left Blank 15 - Section IX. Bilingual Education/ESL, Section 504, and Dyslexia Assurances TEC, Chcrpwer 29, Suhchupler B, TEC'§12.104(b)(2)(G). and 19 TAC,�89.1201-.1265 require charter schools to identify limited EngI ish proficient students based on state criteria and to provide an appropriate bilingual education or English as a second language program conducted by teachers certified for such courses. A.The charter holder certifies that it has policies and procedures in place that ensure that it complies with the legal and regulatory requirements concernin- identitying and providing appropriate educational services to limited English proficient students. 4 Cheer one: ® Yes ❑ No Section 504 of the Rehabilitation Act of 1973. 29 U.S.C. 794. prohibits discrimination on the basis ofdisabilitl, in any program receiving federal financial assistance. A recipient that operates a public education program or activity shall provide a free. appropriate public education to qualified individuals. B.The charter holder certifies that it has policies and procedures in place that ensure that it complies with the legal and regulatory requirements concerning identifying and providing appropriate educational services to students protected by Section 504. Check one: ® Yes ❑ No TEC X38.003. TEC§12.104(b/(2)(K), 19 T4('��-4_28 and Section 504 of the Rehabilitation Act of 1973, 29 U.S.C'. -9-t, requirc charter schools to Identify students N�ith dyslexia or related disorders and to provide appropriate educational services. C.The charter holder certifies that it has policies and procedures in place that ensure that it complies with the legal and regulator-requirements concerning identifying and providing appropriate educational services to students�N itll dyslexia or related disorders. Check one: ❑ Yes ❑ iNo I the undersigned hereby certify that the information contained in this dociunent is,to the best of my knovl iedue. correct and that the aob ern ing bode of the charter holder has authorized me to provide these assurances. ------- --------- -- ----------- --- -------- � � - -- - ---------------- Signature of Charter Hold Board Chair Date (nnrsl sign in blare ink) 16 Section X. Certificate of Ackno led(Yemen t This section requires at least a majority of the governing body of the charter bolder to certify that it has had an opportunih to reviev, the completed reneNval application and has authorized.during an open meeting, submission of the application to the commissioner for consideration of reneNNal of the charter. CERTIFICATE OF ACKNOWLEDGEMENT The undersigned members of the yovernin(body of the charter holder hereby acknowledge that they have had an opportunity to review the completed renewal application and have authorized its submission, during an open meeting. to the commissioner for consideration of the renewal of the charter: '-11017hCTS(11-C 10 Sik17 Me UCA-170lv1 t1,c e171e171 e[111717g(171 011011 McC7117g thei-elbre. Me Cline 17ext 10 each S7g17Ulwv should he ihe.wine Typed Name Signature � (type name next to corresponding signature) I (must si�un in blue ink) Date* I Scott Bradlev > i Fred Held Truitt Bro\\n tI v Francis Free 0 , j Donald Reddin(-7 i Larr\ Corson i I I i � I I N.B. Donald Redding is out of town for an extended time and Larry Corson had to excuse himself from the meeting early to catch a plane, therefore they were unable to sign thv Certificate of Acknowledcyement. We -will have both of these Board members sign another copy when they return to town and we will forward it to you at that time. 17 Dr. Shirley J. Neeley Commissioner of Education Dr. Ernest Zamora Associate Commissioner for Support Services & School Finance Mary Perry Director. Division of Charter Schools For further information contact Monica Sena-Martinez at: DIN-ision of Charter Schools Texas Education A`_=ency 1701 North Congress AX-enue Austin. Texas 78701 (512) 463-9575 (512) 463-9732 fax Or visit our «ebsite: hitp:/'NN Nvw.tea.state.tx.us.charter i8