1. Healthcare

Building the whole person for the whole world with wisdom, stature and favor
Vision
Newman International Academy is dedicated to raising a
generation/generations of well-rounded individuals who will realize their
worth and purpose, find their interest and gifting, develop their skills, reach
their highest potential, and meet the demands of this nation and world by
receiving personalized educational experiences in a disciplined, nurturing
and character-building environment facilitated through partnership between
faculty, students, parents and community.
We are pleased that you have selected Newman International Academy of
Arlington as your school of choice. We are committed to providing a quality
education designed to prepare your child for the international market place and/or
college and career, to become a well-rounded individual who reaches his/her
highest potential in areas of gifting.
Please complete this Sibling Enrollment Packet, sign in the designated areas, and
return the completed packet to the school along with ALL the required
documentation. For a student to receive sibling priority he/she must have a sibling
currently enrolled in Newman International Academy.
Newman International Academy WILLNOT accept incomplete packets. Please
make sure you have completely filled out the entire packet, initialed and signed
where needed, and that all documents are attached with this enrollment packet.
Return the completed packet to the school office.
We look forward to a rewarding school year!
Student Name ____________________
New Student Sibling Enrollment Packet
2015-2016
DOB ____________________________
Grade 2015-2016 _________________
New Student Sibling Enrollment Packet
2015-2016
NEWMAN INTERNATIONAL ACADEMY OF ARLINGTON
2011 S. Fielder Rd., Arlington, TX 76013, 817-459-8555
We are pleased that you have selected Newman International Academy of Arlington as your school of choice. We
are committed to providing a quality education designed to prepare your child for an international market place and
for college and carrier, to become a well-rounded individual who reaches his/her highest potential in areas of gifting.
To be considered a sibling of a current NIAA student, both students must reside in the same household and this
completed enrollment packet must be received in the NIAA front office no later than 2:30pm, Friday February 27,
2015. Any forms received after that time will be placed in the order they are received along with the new student
forms. NO SIBLING PREFERENCE WILL BE GIVEN TO FORMS RECEIVED AFTER 2/27/2015.
Please complete the Enrollment Packet, sign in the designated areas, and return to the school along with ALL the
required documentation.
Newman International Academy WILLNOT accept incomplete enrollment packets. Please make sure you have
completely filled out the entire packet, initialed and signed where needed, and that all documents are attached with
this enrollment packet. Return the completed packet to the school office.
Please call the school office with any questions or if you need help completing the Enrollment Packet.
We look forward to a rewarding school year!
Required Documentation for Enrollment
a.
Completed Enrollment Packet
b.
Copy of Parent’s Driver’s License
c.
Social Security Card/Passport
d.
Current Immunization Records/NO STUDENT will be allowed to start without these records
e.
STAAR/ Test Scores
f.
Report Card/Home School Records
g.
Attendance Record
h.
Special Education Records including, Eligibility, Full Individual Evaluation (FIE), Annual Review and Dismissal
(ARD) or 504 documents
Newman International Academy of Arlington will not discriminate in admissions based on gender, national origin, ethnicity, religion, disability,
academic ability, artistic ability or athletic ability or the district the child would otherwise attend.
Newman International Academy of Arlington will admit students of any race, color, national and ethnic origin to all the rights, privileges,
programs and activities, generally accorded or made available to students at the school.
2
Student Name ____________________
New Student Sibling Enrollment Packet
2015-2016
DOB ____________________________
Grade 2015-2016 _________________
Newman International Academy of Arlington
2015 – 2016 SIBLING APPLICATION FORM
Name(s) and grade(s) of currently enrolled Student(s) at NIAA
Today’s Date:
STUDENT INFORMATION
Student’s Last Name:
First:
Middle:
Birth date:
Social Security Number
Address:
Apt#:
State:
City:
Zip Code:
PARENT/GUARDIAN INFORMATION
Father/Guardian:
Mother/Guardian:
Address:
Apt#
Address:
City/State/Zip Code:
Apt#
City/State/Zip Code:
Home Phone:
Cell Phone:
Home Phone:
Cell Phone:
(
(
(
(
)
)
)
)
Contact e-mail:
I attest that all the above information is true to the best of my knowledge, and I recognize that any falsification
of records is grounds for immediate dismissal.
Parent/Guardian ________________________ Signature ____________________
3
Date _________
Student Name ____________________
New Student Sibling Enrollment Packet
2015-2016
DOB ____________________________
Grade 2015-2016 _________________
Newman International Academy of Arlington
STUDENT DISCIPLINARY ATTESTATION DISCLOSURE
1. Has the student been in an Alternative Disciplinary Campus in the past year?
Yes
No
DAEP (Disciplinary Alternative Education Program)
JJAEP (Juvenile Justice Alternative Education Program)
OTHER (OTRO) ___________________________
When (dates) ________________
For what reason:
________________________________________________________________________
2. Has the student ever been suspended or expelled from school?
Yes
No
When (dates) ____________________________________________________________
3. Does the student have a documented history of criminal offense?
Yes
No
If yes, please explain ______________________________________________________
________________________________________________________________________
4. Does the student have a documented history of discipline problems?
Yes
No
If yes, please explain: ______________________________________________________
________________________________________________________________________
You will be required to provide discipline records as part of the enrollment process.
I attest that all of the above information is true to the best of my knowledge, and recognize that any
falsification of records is grounds for immediate dismissal.
Parent/Guardian Signature: __________________________________ Date:______________
4
Student Name ____________________
New Student Sibling Enrollment Packet
2015-2016
DOB ____________________________
Grade 2015-2016 _________________
STUDENT INFORMATION FORM
STUDENT INFORMATION
Student’s Last Name:
First:
Middle:
Social Security Number
_______ - _______ - ________
Sex:
M
F
Birth date:
Ethnicity (Hispanic, white, etc).
Address:
City/State/Zip Code:
Phone:
SCHOOL INFORMATION
Previous School:
City/State
School Phone Number
(
1. Did the student attend public school last
year?
Yes
No
2. Has the student ever repeated a grade?
Yes
No If yes, which grade did the student repeat?
3. Has the student ever been in any special learning
programs (ESL, Special Education, Dyslexia, GT or 504)?
4. Has the student ever been Home Schooled?
Yes
Yes
)
No
No
What grade(s) was the student Home Schooled?
If yes please name the program and grade in which
student was enrolled in the program:
Please include all Special Education and 504 records with
this application, along with your child’s full individual
evaluation, eligibility report, and last ARD or 504
form. Please contact your previous school for records.
Campus ID of Residency: (list the closest public
school to your home that your child would
normally attend if he/she were not attending a
charter school.)
5. In the past year, has the student been serviced under the Special Education umbrella in any of the
following areas:
Resource Math
Resource English
Resource Social Studies
Resource Science
Speech Services
Occupational Therapy
Physical Therapy
Intellectual Disability
Content Mastery
Assistive Technology
Counseling
Visually Impaired
Hearing Impaired
I attest that all the above information is true to the best of my knowledge, and recognize that any
falsification of records is grounds for immediate dismissal.
Parent Signature ________________________________________________ Date _________________
5
Student Name ____________________
New Student Sibling Enrollment Packet
2015-2016
DOB ____________________________
Grade 2015-2016 _________________
Newman International Academy of Arlington
EMERGENCY INFORMATION SHEET
SIBLING OF (CURRENT STUDENT ENROLLED AT NIAA) ________________________________________
STUDENT INFORMATION
Student’s Last Name
First
Street address
Apt Number
Home Phone
(
Middle
Sex:
M
F
Date of Birth
City/State
Zip Code
Child lives with Parent?
Mother/Father/Both/Other
)
LEGAL
GUARDIAN
PARENT/GUARDIAN INFORMATION
Father’s Last Name
Street address
First Name
Middle Name
Home Phone
(
)
Apt Number
City/State/ZIP
Cell
(
)
Employer
Employer Phone
Occupation
Email
Mother’s Last
Name
Street address
First Name
Middle Name
Home Phone
(
)
Apt Number
City/State/ZIP
Cell
(
Employer
FAMILY STATUS
Employer Phone
Single
Married
Occupation
Separated
)
Email
Divorced
Other _________
In case my child becomes seriously ill or is injured and neither parent can be reached by phone, please notify
the following person (s): Please list two contacts that do not live in the household.
Primary Emergency Contact:
Relationship
Driver’s License # & State
Phone
(
)
2nd Phone
(
)
Secondary Emergency Contact:
Relationship
Driver’s License # & State
Phone
(
)
2nd Phone
(
)
Third Emergency Contact:
Relationship
Driver’s License # & State
Phone
(
)
2nd Phone
(
)
6
Student Name ____________________
New Student Sibling Enrollment Packet
2015-2016
DOB ____________________________
Grade 2015-2016 _________________
Newman International Academy of Arlington
STUDENT RELEASE AUTHORIZATION
Kindergarten-12th Grades
Dear Parents/Guardians:
Helping our students get home safely and in accordance with parent instructions is a primary concern at
Newman International Academy. In order to ensure our students safety concerning pickup from school
and/or a designated routine to return home, we would like your help in this important matter.
For the safety of our students, any individual other than parents/guardians who arrive to pick up a
child without a release card will be asked to report to the office for proper identification. A valid form
of identification is required when submitting this form. You will be issued a Student Release Card (K-5),
which must be presented to pick-up your child. If you do not have your card or lose it, you must report
to the office for a new card, no exceptions.
Any changes to this form must be made in person by student’s Parent and or Guardian.
My child’s authorized method of getting home after school each day is:
Car Pick-up
Bicycle
Walking
Name of Day Care
Day Care
Phone _____________________
The following adults may pick up my child from Newman International Academy of Arlington (Parent/Guardian
do not list yourself.):
Name
Driver’s License Number
Driver’s
License State
Phone
I understand that my child will not be released into the custody of any person who does not possess a
Student Release Card or is not on the above list. I also understand that it is my responsibility to inform
the school (in writing) of any changes that need to be made to the above list.
Print Parent/Guardian Name
Parent/Guardian Signature
7
Student Name ____________________
New Student Sibling Enrollment Packet
2015-2016
DOB ____________________________
Grade 2015-2016 _________________
Newman International Academy of Arlington
Authorization for Release of Records
_________________________________
Name of Former School
__________________________________
Name of School District
___________________________________
Fax Number
From the office of the registrar:
The following student has enrolled in Newman International Academy:
_____________________________
Student’s Name
_______________________
Grade 2014-2015
______________________
Date of Birth
I give permission for all school records to be released to Newman International Academy.
Legal Guardian/Parent’s Signature
To above student’s former school:
Please fax, email or mail the above student’s transcript, along with the necessary documents that are
checked below needed for enrollment.
Thank you for your assistance.
Date of Request ______________________
Fax to: Newman International Academy of Arlington- 817-394-6155 or email to
[email protected]
 Complete transcript of grades and last report






 Behavior Documentation/Suspensions/Expulsions
card
Standardized test scores (STAAR, TAKS, TELPAS, etc.)
Copy of Birth Certificate
Social Security Card or Student PEIMS ID#
Immunization/Medical Records
Attendance Record
LPAC Folder





8
Special Education
504 & Dyslexia Records
Speech, Occupational, and/or Physical Therapy
ESL Bilingual Assessment Records
Home Language Survey
Student Name ____________________
New Student Sibling Enrollment Packet
2015-2016
DOB ____________________________
Grade 2015-2016 _________________
Newman International Academy of Arlington
HOME LANGUAGE SURVEY
Student’s Name: ______________________________
Date: ___________________
TO BE FILLED IN BY PARENT OR GUARDIAN
1.
What language is spoken in your home most of the time?
__________________________
2.
What language does your child speak most of the time?
__________________________
3.
Has your child ever lived outside of the U.S?
__________________________
4.
When did he/she enroll in a U.S. School?
__________________________
Parent/Guardian Signature: _______________________
9
Date:___________________
Student Name ____________________
New Student Sibling Enrollment Packet
2015-2016
DOB ____________________________
Grade 2015-2016 _________________
Newman International Academy of Arlington
MIGRANT SURVEY
Dear Parent
Newman International Academy is helping the State of Texas identify students who may qualify for
the Migrant Program services that provide extra help in academics.
Please answer the following questions:
Student’s Name: _____________________________________________________
Has your family moved any time during the last three years from one school district to another in
Texas or across state lines?
Yes
No
Were any of these moves made to find temporary or seasonal work in agriculture-related job:
packing, processing, harvesting, cultivating of crops, food processing, daily work, forestry, fishing,
etc.?
Yes
No
If you answer “yes” to question #2, please complete the information below.
Name of Parent/Guardian: ________________________________________________________
Address: _______________________________________________________________________
Phone: _________________________________________________________________________
List names and ages of children who are not enrolled in school.
Age
___________________
Last Name
___________________
First Name
___________________
Middle Name
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
10
Student Name ____________________
New Student Sibling Enrollment Packet
2015-2016
DOB ____________________________
Grade 2015-2016 _________________
Texas Education Agency
Texas Public School Student/Stall Ethnicity and Race Data Questionnaire
Newman International Academy of Arlington
The United States Department of Education (USDE) requires all state and local education institutions to collect data on
ethnicity and race for students and staff. This information is used for state and federal accountability reporting as well as for
STUDENT RESIDENCY QUESTIONNAIRE
reporting go the Office of Civil Rights (OCR) and the Equal Employment Opportunity Commission (EEOC).
School district staff and parents or guardians of students enrolling in school are requested to provide this information. If you
decline
to provide
this information,
please be aware that the USDE requires school districts to useGender:
observer identification
as a
Name
of Student:
_____________________________________________________
Male
last resort for collecting the date for federal reporting.
Last
First
Middle
Female
Please answer both parts of the following questions on the student’s or staff member’s ethnicity and race.
Date
of Birth:
Grade: ________________ ID#: ___________________
United
States
Federal_______/_______/_______
Register (71FR 44866)
Part 1. Ethnicity:
person Year
Hispanic/Latino? (Choose
only one)
MonthIs theDay
(preschool-12)
(Optional)
□Hispanic/Latino – A person of Cuban, Mexican. Puerto Rican, South or Central American, or other Spanish
Address:
___________________________________________________
culture
or origin,
regardless of race.
Phone: _________________
□Not Hispanic/Latino
2.you
Race:
Whatwill
is help
the the
person’s
race? (Choose
oneyou
orormore)
ThePart
answer
give below
district determine
what services
your child may be able to receive under the McKinneyVento Act. Students who are protected under the McKinney-Vento Act are entitled to immediate enrollment in school even if they don’t
American
Indian or Alaska Native – A person having origins in any of the original peoples of North and South
have the documents normally needed, such as proof of residency, school records, immunization records, or birth certificate.
□
□American (including Central America), and who maintains a tribal affiliation or community attachment.
Where is the student currently living? (Please check one box.)
□Asian – A person having origins in any of the original people of the Far East, Southeast Asia, or the Indian
subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine
In a shelter
Islands, Thailand, and Vietnam.
With another family or other person (sometimes referred to as “doubled-up”)
Black or
American - A person having origins in any of the black racial groups of Africa.
In African
a hotel/motel
a car, park,
bus, train,
orIslander
campsite– A person having origins in any of the original peoples of Hawaii,
NativeInHawaiian
or Other
Pacific
Otheror
temporary
living
situation (Please describe): _______________________________________
Guam Samoa,
other Pacific
Islands.
In permanent housing
White – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
In Foster Home
□
□
□
__________________________________
Student/Staff Name (please print)
__________________________________
Print
name of Parent, Guardian, or Student
Student/Staff
Identification
Number
(if unaccompanied
homeless youth)
______________________________________
Parent/Guardian)/(Staff) Signature
Signature of Parent, Guardian, or Student
(if unaccompanied homeless youth)
This space is reserved for Local school observer – upon completion and entering date in student software system,
file this form in student’s permanent folder.
Race – Choose one or more
Date
Ethnicity – choose only one
□Hispanic/Latino
□Not Hispanic/Latino
□American Indian or Alaska Native
□Asian
□Black or African American
□Native or Other Pacific Islander
□White
11
Student Name ____________________
New Student Sibling Enrollment Packet
2015-2016
DOB ____________________________
Grade 2015-2016 _________________
We are required to include these two codes for every student for State Reporting (PEIMS).
Please check the applicable box for each category.
Military-Connected-Student-Code
o Not a military connected student
o Student is a dependent of a member of the Army, Navy, Air Force, Marine Corps, or
Coast Guard on active duty
o Student is a dependent of a member of the Texas National Guard (Army, Air Guard
or State Guard)
o Student is a dependent of a member of a reserve force in the United States military
(Army, Navy, Air Force, Marine Corps, or Coast Guard)
o Pre-kindergarten student is a dependent of: 1) an active duty uniformed member of
the Army, Navy, Air Force, Marine Corps, or Coast Guard, 2) activated/mobilized
uniformed member of the Texas National Guard (Army, Air Guard, or State Guard),
or 3) activated/mobilized members of the Reserve components of the Army, Navy,
Marine Corps, Air Force, or Coast Guard, who are currently on active duty or who
were injured or killed while serving on active duty.
Foster-Care-Indicator-Code
o Student is not currently in the conservatorship of the Department of Family and
Protective Services
o Student is currently in the conservatorship of the Department of Family and
Protective
Services
o Pre-kindergarten student was previously in the conservatorship of the Department
of Family and Protective Services following an adversary hearing held as provided by
Section 262.201, Family Code.
Parent Signature: _________________________________Date: _____________
12
Student Name ____________________
New Student Sibling Enrollment Packet
2015-2016
DOB ____________________________
Grade 2015-2016 _________________
Newman International Academy of Arlington
HEALTH LETTER
Dear Parent:
In order to effectively meet your child’s needs during the school year, it is necessary to obtain certain health
information and current phone numbers where parents or another designated adult can be reached in case of an
emergency. As a school we have also instituted specific procedures and policies that must be followed to protect
your student who attends Newman International Academy. These procedures and policies are as follows:
IMMUNIZATIONS



All immunization records must be presented at time of application to the school and must be up to date.
It is the responsibility of the parent to keep immunizations current.
A written record of administration of the needed immunization must be given to the school nurse or her
representative within one month of the due date.
 The child will not be allowed to come to school until the child has received the immunization and the
nurse has received the record.
MEDICATIONS
The school nurse or other trained non-healthcare personnel may administer medication when such treatment is
necessary for school attendance and cannot otherwise be accomplished. All medications, given three times per
day or less, should be given outside of school hours. For example: three times a day medications can be given
before school, after school, and at bedtime. If necessary for medications to be given at school the following
conditions must be met:
Prescribed medication:




The first dose must be given at home in case of unexpected allergic reaction.
Medication must be brought in by parent in original container, properly labeled by the pharmacy.
Parents must supply any special equipment necessary to administer medication.
Medication will not be given without specific written request signed by a parent/guardian and
physician.
Medication must be kept in the clinic, with the exception of inhalers that physicians may deem
necessary for student to carry on their person. In this case, physician must complete the
authorization to self-administer. All rules regarding medication given at school still apply. If
student is misusing inhaler, the privilege will be revoked. A second inhaler should be kept in the
clinic.
Over-the-counter medications: Same rules apply as with prescribed medications except that they can be
given with parent authorization only, physician signatures are not required. The medication can only be
given as directed by the manufacturer and must be FDA approved.
End of the school year: All medications must be picked up from the clinic by the last day of school. Any
medications left at the school will be disposed of by the nurse the following day.
13
Student Name ____________________
New Student Sibling Enrollment Packet
2015-2016
DOB ____________________________
Grade 2015-2016 _________________
ILLNESS


Students must be free from fever, vomiting and/or diarrhea without fever reducing medications for
twenty-four hours before returning to the school after an illness.
No child with any type of communicable disease will be allowed to attend school until the disease has run
its course and the child is no longer contagious. It will be the decision of the school nurse and/or
administrative staff whether or not a child is ready to return to school after an illness with a contagious
disease.
RESTRICTION OF ACTIVITY


Any student requiring restriction from any type of physical activity must have a written statement by their
physician. The restriction of the physical activity must be clearly stated.
If the student wishes to participate in a restricted activity, the physician must give a written statement
that the student is physically able to participate in the activity.
EMERGENCY CONTACT

It is imperative that school officials be able to contact one of the parents or a designated emergency
contact in the event of a medical emergency or other incident occurring with your child. Any change of
phone number must be given to the school office immediately; we must be able to contact you at all
times.
I agree to fully cooperate with the above policies and procedures.
Parent/Guardian Signature: _______________________
14
Date:___________________
Student Name ____________________
New Student Sibling Enrollment Packet
2015-2016
DOB ____________________________
Grade 2015-2016 _________________
Newman International Academy of Arlington
NURSES EMERGENCY INFORMATION SHEET
STUDENT INFORMATION
Student’s Last Name
First
Middle
Street address
Apt
Home Phone
(
)
Child lives with Parent?
Sex:
F
Date of Birth
City/State
LEGAL GUARDIAN
Zip Code
Mother/Father/Both/Other
PARENT/GUARDIAN INFORMATION
Father’s Last Name
First Name
Middle Name
Street address
Apt Number
City/State/ZIP
Employer
Employer Phone
Occupation
Mother’s Last
Name
Street address
First Name
Middle Name
Apt Number
City/State/ZIP
Employer
Employer Phone
Occupation
FAMILY STATUS
M
Single
Married
Separated
Home Phone
(
)
Cell
(
)
Email
Home Phone
(
)
Cell
(
)
Email
Divorced
Other _________
EMERGENCY INFORMATION
In case of a MEDICAL EMERGENCY, the school will call the paramedics and your child will be transported to the
Nearest Emergency Room for immediate care.
YES
NO 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 that
neither parent/guardian can be reached in the case of an emergency.
Physician’s Name
Address
City
Telephone
(
)
Preferred Hospital:
In case my child becomes seriously ill or is injured and neither parent can be reached by phone, please notify
the following person (s): Please list two contacts that do not live in the household.
Primary Emergency Contact:
Relationship Phone
2nd Phone
3rd Phone
Secondary Emergency Contact:
Relationship
Phone
2nd Phone
3rd Phone
Third Emergency Contact:
Relationship
Phone
2nd Phone
3rd Phone
15
Student Name ____________________
New Student Sibling Enrollment Packet
2015-2016
DOB ____________________________
Grade 2015-2016 _________________
Student Health History/Nurses Office Only
Does student have: (please circle answer)
Allergies:
Yes
If yes:
No
Pollen?
Are the allergies severe?
Drugs?
Yes
No
Foods? Insects?
Other: (Explain) _________________________________________________________________
Has emergency care been needed in the past for allergic reaction or injuries?
Yes
No
If yes: Hospitalization _________________ Medication Only____________________________
Is your child required to carry an Epi-Pen with them?
Asthma Yes
No
Yes
No
Triggered by: __________________ Treat with: _______________
Does your child require daily use of an inhaler or require breathing treatments? Yes
No
Describe inhaler use and/or breathing treatments: ____________________________________
_____________________________________________________________________________
Diabetes
Yes
No
Controlled by: _________________ Diet ________________
Emotional Disorders
Yes
No
Controlled by: _____________________________
Seizures
Yes
No
Any restrictions? ___________________________
Bone/Joint Disorders
Yes
No
Any restrictions? ___________________________
Frequent Headaches
Yes
No
Vision/Hearing Problems
Yes
No
Glasses Yes
No
Contacts
Yes
No
Hearing Aids
Yes
No
List any other serious illness or condition not mentioned above: _________________________
Daily Medications
Yes
No
At home: ________________ At school: _______________
Medications
List all medication you child is currently taking, not just those needed during school hours.
Medication
Dosage
Route
Frequency
Indications
____________________________ __________
__________
___________
____________________
____________________________ __________
__________
___________
____________________
____________________________ __________
__________
___________
____________________
____________________________ __________
__________
___________
____________________
I AGREE THAT THE TEACHER & PERTINENT PERSONNEL BE ALLOWED TO KNOW THE ABOVE
INFORMATION
Signature _____________________________________________ Date ___________________
16
Student Name ____________________
New Student Sibling Enrollment Packet
2015-2016
DOB ____________________________
Grade 2015-2016 _________________
Newman International Academy of Arlington
COMPUTER/INTERNET USE PERMISSION
I agree to abide by the Technology Acceptable Use policy in the Student Code of Conduct. I
give permission for my child to use Newman International Academy computers for
assignments, research, documents and projects. If at any time he/she accesses any illegal
site, downloads information, infringes on the copyright law, damages the computer/property
of the Newman International Academy, he/she shall be responsible for replacing the
property and/or may be denied access to use of the computer for a time to be determined by
the instructor and the school or other disciplinary action as stated in the student code of
conduct. Student work could be published and displayed.
_________
MEDIA RELEASE
Anyone who attends NIAA will be photographed for the yearbook and possible film, video,
and/or audio tape recordings, photographs during classroom instructions, assessments and
other school related activities. This media will be produced for educational and promotional
purposes for NIAA only. The school has an on campus photographer and videographer that
will photograph groups of unidentified (unnamed) students that will appear in video
productions or the yearbook.
In a school our size, we cannot be responsible to remove your child/children from each group
being photographed. You must inform your child to respectfully stand aside if they know that
they are in a group bring photographed.
I agree to the media policy of NIAA and understand that my child will be photographed and will
appear in videos that promote the school.
You do not have my permission for identified films, video/audio tape recordings, or photos,
including the annual yearbook.
PLAYGROUND RELEASE
_________
I give my child permission to play on the playground at Newman International Academy. I
understand that Newman International Academy will not be liable for any accident or injury
to my child.
Print Student’s Name:________________________
Student’s Signature: ________________
Print Parent/Guardian Name: ____________________________________________________
Parent/Guardian Signature: ______________________________________________________
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Student Name ____________________
New Student Sibling Enrollment Packet
2015-2016
DOB ____________________________
Grade 2015-2016 _________________
Newman International Academy of Arlington
Socioeconomic Information Form
*CONFIDENTIAL*
Student Name ____________________________ Student Grade______Date of Birth _________
NIAA is required to collect and report the socioeconomic status of each student to the Texas Education
Agency for purposes of the annual state accountability ratings and for federal reporting. Please note that
this form is not sent to the Texas Education Agency and that the income levels indicated for your family
are not reported to the Texas Education Agency. Only the Economic Disadvantaged status of each
student as determined by the information provided is reported to the Texas Education Agency.
SECTION A
Do you receive Supplemental Nutrition Assistance (SNAP)?
 Yes  No
Do you receive Temporary Assistance to Needy Families (TANF)?
 Yes  No
If you answered YES on either of the above, skip SECTION B and continue to the SIGNATURE
section.
SECTION B (Complete only if all answers in SECTION A are NO)
How many members are in the household (include all adults and children)?
TOTAL YEARLY INCOME BEFORE DEDUCTIONS OF ALL HOUSEHOLD MEMBERS (check one
box below):
Include wages, salary, welfare payments, child support, alimony, pensions, Social Security,
worker’s compensation, unemployment and all other sources of income (before any type of
deductions)
 $0 – 21,590
 $21,591 – 29,101
 $29,102 – 36,612
 $36,613 – 44,123
 $44,124 – 51,634
 $51,635 – 59,145
 $59,146 – 66,656
 $66,657 – 74,167
 $74,168 – 81,678
 $81,679 – 89,189
 $89,190 – 96,700
 $96,701 – 104,211
 $104,212 – 111,722
 $111,723 – 119,233
 $119,234 – 126,744
 $126,745 and above
SIGNATURE Please check one of the following two boxes as appropriate.
In accordance with the provisions of the Protection of Pupil Rights Amendment (PPRA) no student shall be
required, as part of any program funded in whole or in part by the U.S. Department of Education, to submit
to a survey, analysis, or evaluation that reveals information concerning income (other than that required by
law to determine eligibility for participation in a program or for receiving financial assistance under such
program), without the prior written consent of the adult student, parent or legal guardian.
 I certify that all the information on this form is true and that all income is reported. I
understand the school will receive federal funds and will be rated for accountability based on the
information I provide.
 I choose not to provide this information. I understand that the school’s disbursement of federal
funds and accountability rating may be affected by my choice.
Parent/Guardian Name (Print)
Parent/Guardian Signature
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Date
Student Name ____________________
New Student Sibling Enrollment Packet
2015-2016
DOB ____________________________
Grade 2015-2016 _________________
Contact Information Form
NIAA uses e-mail as a regular point of contact with our parents. This will be used to send out
reminders, Friday letters, etc.
The Contact Number will be used to call you when we send a SchoolReach call.
Please consider this information carefully and make an effort to keep us informed as soon as
possible any information changes for any reason.
You can e-mail any changes to Jackie Cantrell at [email protected]
Please print clearly
Contact e-mail _______________________________________________________________
Contact e-mail _______________________________________________________________
Contact Number: ( ____ ) ____ - ______
Child 1: Last Name:
First Name:
Grade: ___________________
Child 2: Last Name:__________________________ First Name: ________________________
Grade: ___________________
Child 3: Last Name:__________________________ First Name: ________________________
Grade: ___________________
Child 4: Last Name: __________________________First Name:________________________
Grade: ___________________
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