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Intent to Return Form

Let’s get started! According to our records, the following students are currently enrolled at Commonwealth Charter Academy. Please tell us whether or not each student will be returning for the 2017-2018 school year by toggling between “Returning” or “Not Returning.” Once you’ve completed this section, please select “Start” to continue. If your student is currently enrolled in CCA but his/her name is not listed, please contact us immediately at 844-590-2864.

Returning

Not Returning

Your Household Information

Let’s take a closer look at the information we have on file for your Household. Please review the information listed below carefully and update anything that may be incorrect. Once you’ve verified your information, please select “Next” to continue.

Please note that all curriculum and equipment must be shipped to this address. Post office boxes cannot be used for the home address.

Please​ ​note,​ ​CCA​ ​will​ ​use​ ​this​ ​address​ ​to​ ​schedule​ ​a​ ​pick​ ​up​ ​with​ ​UPS​ ​to​ ​retrieve all​ ​CCA​ ​issued​ ​equipment.​ ​Post​ ​office​ ​boxes​ ​cannot​ ​be​ ​used​ ​for​ ​the​ ​home address


Yes, this is my current home address.

No, this address is not correct.

One or more phone numbers must be provided. If you have included more than one, be sure your primary number is on the top of the list by clicking on the handle to the left and dragging the number to the top of the list.

One​ ​or​ ​more​ ​phone​ ​numbers​ ​must​ ​be​ ​provided​ ​to​ ​schedule​ ​a​ ​pick​ ​up​ ​of​ ​your​ ​CCA issued​ ​equipment.​ ​If​ ​you​ ​have​ ​included​ ​more​ ​than​ ​one,​ ​be​ ​sure​ ​your​ ​primary​ ​phone number​ ​is​ ​on​ ​the​ ​top​ ​of​ ​the​ ​list​ ​by​ ​clicking​ ​on​ ​the​ ​handle​ ​to​ ​the​ ​left​ ​and​ ​dragging​ ​the number​ ​to​ ​the​ ​top​ ​of​ ​the​ ​list.

Not Provided

Add A Number

The information below will be used to determine federal funding. The details will also be used to determine eligibility for FREE CCA events. View CCA Family Income Form FAQs.

Please include both children and adults.

Do you or any of the members in your household currently participate in one or more of the following assistance programs: School Nutritional Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) and/or Food Distribution Program on Indian Reservations (FDPIR)?

If yes, please indicate which program(s) by checking the box to the left and providing your case number in the list below. Please select all that apply.

You may decline to provide your gross annual income; however, this may impact Federal Funding provided to CCA for additional programs, benefits, and services. Please select if you wish to provide or decline to provide your income.

Yes, I agree to provide my income information.
My gross annual income before taxes is:

No, I choose not to provide my income information.

Although your student is attending a virtual school, there may be instances when it is necessary to contact a parent or legal guardian in an emergency situation. If a parent or legal guardian cannot be contacted, we attempt to contact the individuals listed below (in the order they are listed).

Primary Phone:

Secondary Phone:

Relationship to Student(s):

Primary Phone:

Secondary Phone:

Relationship to Student(s):

Households may be eligible to receive an Instructional Technology Support subsidy. Please indicate the first and last name of the household member to whom the Instructional Technology Support subsidy payment should be made payable. Reimbursement will be made payable to the name provided, and will be mailed to the household mailing address.

No Name Provided

Yes, this name is correct.

No, this name is not correct.

I understand that all materials and equipment provided by the school remain the property of the school and must be returned at the school’s request. These items must be used according to the terms of the School Handbook. I am responsible for ensuring that any member of my household complies with these terms and that any violation could result in a repossession of the equipment. I also understand that the school has the right to monitor the use of the equipment and to disable it if unauthorized use occurs or if the equipment is not returned as requested.

I will keep all packaging supplies for learning materials or equipment provided by the school and must return any learning materials and equipment in the original packaging. If packaging is lost or damaged, I will be responsible for purchasing replacement packing materials.

I understand that this school requires the use of the Internet on a regular basis, and that I am responsible for obtaining and setting up an Internet account that meets minimum standards for speed, availability, and compatibility.

I certify that I have the legal authority to make educational decisions for .

Current Grade:

As we plan for the 2017-2018 school year, we have a few questions about . Please read and answer the questions below carefully. Once you’ve completed this section, please select “Next” to continue.

Current Grade:

We’ve​ ​loved​ ​having ​ ​enrolled​ ​at​ ​CCA,​ ​and wish​ ​he/she​ ​the​ ​best​ ​of​ ​luck​ ​as​ ​they​ ​continue​ ​their​ ​education!​ ​Please​ ​take​ ​a​ ​moment​ ​and tell​ ​us​ ​about​ ​your​ ​student’s​ ​future​ ​plans.​ Once you’ve completed this section, please select “Next” to continue.

Yes, is returning to CCA

No, is not returning to CCA

Many of our students communicate directly with their teachers and school counselors. If you agree to allow direct communication between your student and his/her teachers, please supply their cell phone number.

Yes

No

Click here to view more information about CCA's summer school program.

Yes, I am interested

No, I am not interested

Please see below for additional details about each program. All selections will be reviewed and discussed with with your student’s homeroom teacher and/or School Counselor.

Please select all that apply:

More Info

Original credit refers to any course the student would like to take for enrichment and may be a course that the student has not previously earned credit in. A student may take this course as a summer enrichment opportunity or as an opportunity to earn credits towards graduation if they are in need of additional credit to be on track with his/her cohort grade level. All selections will be reviewed and discussed with with your student’s homeroom teacher and/or School Counselor.

More Info

Credit recovery refers to any course that was previously taken by the student where a failure grade was received or no credit was earned. Students may retake that course to earn that credit. All selections will be reviewed and discussed with with your student’s homeroom teacher and/or School Counselor.

Please tell us what subject you are interested in taking for Original Credit by selecting from the options below. All selections will be reviewed and discussed with with your student’s homeroom teacher and/or School Counselor.

Please select a maximum of two options:

Please tell us what course you are interested in taking for Credit Recovery by selecting from the dropdown below. All selections will be reviewed and discussed with with your student’s homeroom teacher and/or School Counselor. Click here to view a full list of summer school courses.

Click here to view more information about CCA's summer school program.

Yes, I am interested

No, I am not interested

The Family Educational Rights and Privacy Act (FERPA) permits the school to disclose a student’s FERPA Directory Information to third parties unless the parent requests that this information be withheld. CCA considers the following student directory information: Student Name, Student Webmail (within Connexus) address, Student’s City of Residence, Student’s Phone Number, and Student’s Grade Level.

A decision to withhold direction information also means that the school cannot include the student’s information in the School Directory (see below). Please indicate that you have read and understand the FERPA Annual Notification by initialing the box to the left of the statement below.

I have read and understand the FERPA Annual Notification and permit the school to include the student’s information in the school’s FERPA Directory Information.

Commonwealth Charter Academy School Directory is where students and parents can find information about other families within CCA. The information is limited to the Student’s Name, City of Residence, Grade Level, WebMail Address (within Connexus) and Parent/Legal Guardian Name.

Please indicate that you have read and understand the School Directory agreement by initialling the box to the left of the statement below.

I permit the school to include my student’s information in the School Directory.

The Pennsylvania Department of Health requires all schools to report statistical information on students dealing with chronic conditions. Please check all conditions below that apply to your child. Your child’s name will not be included in the state report.

Please select all that apply:

More Info

A disease which causes chronic inflammation of the joints. Include juvenile rheumatoid arthritis (JRA), lupus erythematosus, fibromyalgia, gout, Lyme disease, or other forms of arthritis.

More Info

Deficiency of the factors necessary for coagulation of the blood (Factor VIII, Factor IX, Factor XI, etc.) whether severe, moderate or mild. Includes Thalassemia major (Cooley’s anemia), which is a defect in the synthesis of hemoglobin A and is characterized by impaired red blood cells. Do not include sickle cell disease.

More Info

Congenital anomalies of the heart and acquired heart conditions such as valve disorders, cardiomyopathy, Kawasaki disease, myocarditis, familial hypercholesterolemia, secondary hypertension. Do not include “innocent” heart murmurs.

More Info

Previously known as juvenile-onset diabetes, disorder characterized by lack of insulin production in the pancreas.

More Info

Previously known as adult-onset diabetes, disorder characterized by the pancreas’ inability to produce sufficient insulin, or the body’s inability to utilize insulin efficiently.

More Info

Neurological disorders caused by sudden uncontrolled episodes of excessive electrical discharge from brain cells resulting in seizures in which movement, consciousness or behavior may be impaired for short periods of time. Not all seizure disorders are manifestations of epilepsy.

More Info

Defined as one who has life-threatening anaphylaxis, caused by a reaction to food allergies that substantially limits a major life activity.

More Info

Defined as one who has life-threatening anaphylaxis, caused by a reaction to bee-stings, latex, etc that substantially limits life activity.

More Info

Inherited blood disease that is due to the presence of abnormal sickle shaped hemoglobin in the red blood cells. Include sickle cell anemia, sickle hemoglobin C and E disease, and combination sickle cell thalassemia. Do not include sickle cell trait.

Section 9528 of the Elementary and Secondary Education Act of 1965 (ESEA) requires that a school disclose a student’s name, address and telephone number to military recruiters upon request, unless a parent requests that this information not be disclosed without written consent.

Please indicate that you have read and understand the Military Release Agreement by initialling the box to the left of the statement below.

I permit the release of my student’s information to military recruiters.

Please indicate your student’s plans for the year immediately following their high school graduation using the dropdown menu below.

Yes

Please indicate if the statement is true by selecting the checkbox to the left of each statement.

No

If the selections below are not consistent with the student’s past academic performance, a teacher or guidance counselor will call you to discuss whether or not these choices are appropriate.

Standard
This is the typical level of courses that most students select. These courses prepare students for post high-school learning such as trade school or college.

Honors
For students who prefer learning at an accelerated pace with challenging concepts. This is similar to the standard courses with added extensions that may require more independent study.

Advanced Placement
AP courses are college-level courses. There are prerequisites for these courses and they are taken almost exclusively by students in grade 11 and 12.

List up to four elective courses for each semester (total of 8 selections) in order of preference, with #1 being the selection most preferred and #4 being the selection least preferred. Click and drag the handle to the left to move it in the list.

It is recommended that students provide four electives per semester; however, to offer a level of flexibility only the first two electives per semester are required. Visit our Course Catalog for full course descriptions.

Fall Semester

Spring Semester

Click the “Next” button at the bottom of your screen to continue to the next step. Or you can submit ’s form immediately by visiting the Review and Submit section.

Please​ ​let​ ​us​ ​know​ ​why​ ​your​ ​student​ ​is​ ​not​ ​coming​ ​back​ ​to​ ​CCA​ ​for​ ​the​ ​2017-2018 school​ ​year.​ ​We​ ​use​ ​this​ ​information​ ​for​ ​state​ ​reporting,​ ​as​ ​well​ ​as​ ​to​ ​make improvements​ ​to​ ​our​ ​school​ ​and​ ​curriculum. Please use the dropdown menu below.

Congratulations on your graduation! We're excited to know what you plan to do next. Please select an option from the list below that best describes your plans for the year immediately following your high school graduation.

Please provide the name of the college you will be attending next year.

Please select the state from the dropdown list below where you will be attending college next year.

Please provide the name of the vocational school you will be attending next year.

Please select the state from the dropdown list below where you will be attending vocational training next year.

Please​ ​provide​ ​the​ ​name​ ​of​ ​the​ ​school​ ​you​ ​will​ ​be​ ​attending​ ​next​ ​year.

Please​ ​provide​ ​the​ ​type​ ​of​ ​the​ ​school​ ​you​ ​will​ ​be​ ​attending​ ​next​ ​year.

Please provide the name of the school district you will be attending next year.

Please select the state from the dropdown list below where you will be attending next year.

For students not returning for the 2017/2018 school year, CCA owned equipment and curriculum will need to be returned. There will be separate labels for the laptop and curriculum.

You will receive an e-mail and instructions explaining when your laptop will be picked up. UPS will have a label and will make 3 attempts to pick up the package. Please ensure the laptop is re-packed in its original packaging and ready for UPS pick-up. Laptops will be shipped to CCA in Middletown, PA. If the equipment is not returned the household may be invoiced. Curriculum return labels and instructions will be mailed to you as well.

Click the “Next” button at the bottom of your screen to continue to the next step. Or you can submit ’s form immediately by visiting the Review and Submit section.

Review & Submit

You are almost finished! Please take a moment and carefully review the details below to ensure everything is accurate. If everything is correct, Please select the “Submit” button for each student to complete your submission. You will receive an email confirmation once CCA has received your form.

Fields highlighted in red must be completed before submitting this section. Please return to the Household section to complete any missing details

Return

Street Not Provided

City Not Provided
State Not Provided
Zipcode Not Provided
Not Provided
:
Not Provided
None SNAP: Case Number:
TANF: Case Number:
FDPIR: Case Number:
Not Provided $
Yes, withhold income information
Primary Emergency Contact Not Provided

Primary Phone:
Secondary Phone:
Relationship to Student(s):
Secondary Emergency Contact Not Provided
Primary Phone:
Secondary Phone:
Relationship to Student(s):
Not Provided Not Provided
Materials and Equipment
Materials and Equipment
Packaging Supplies
Packaging Supplies
Internet Utility
Internet Utility
Legal Authority Legal Authority

Fields highlighted in red must be completed before submitting this section. Please return to the Student section to complete any missing details

Return
Not Provided Not Provided
No, is not interested in the summer program Yes, is interested in the summer program
Not Provided
Not Provided
Include in FERPA Directory No, don't include in FERPA Directory
Include in School Directory No, don't include in School Directory
Release info to military recruiters No, don't release info to military recruiters
Not Provided
Yes, is interested in NCAA No, is not interested in NCAA
Not Provided
Yes, discuss eligiblity with school counselor No, do not discuss eligiblity with school counselor
Yes, eligiblity was previously discussed No, eligiblity was not previously discussed
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Not Provided
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First Choice: Not Provided
Second Choice: Not Provided
Third Choice: Not Provided
Fourth Choice: Not Provided
First Choice: Not Provided
Second Choice: Not Provided
Third Choice: Not Provided
Fourth Choice: Not Provided
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