¡Si Se Puede!
Mission:
To provide a safe atmosphere of academic excellence that promotes
thinkers and problem solvers who work cooperatively and respectfully in an
inclusive environment.
2015-2016 School Year
Elementary (K-2)
8126 W. Vernor Hwy.
Detroit, MI 48209
Ph. # 313.843.9440
Fax # 313.297.6948
G. Jaime, Leader
Elementary (3-5)
4100 Martin
Detroit, MI 48210
Ph. # 313.361.1083
Fax # 313.361.1095
T. Goodley, Leader
Elementary (K-5)
4130 Maxwell
Detroit, MI 48214
Ph.# 313.924.0317
Fax # 313.924.0425
A. Philyaw, Leader
Middle School (6-8)
6782 Goldsmith
Detroit, MI 48209
Ph. # 313.842.0006
Fax # 313.842.0167
K. VonKeltz, Leader
High School (9-12)
1761 Waterman
Detroit, MI 48209
Ph. # 313.551.0611
Fax # 313.551.0552
J. Martinez, Leader
Dear Parent or Guardian:
Thank you for enrolling your child (ren) in César Chávez Academy. As a charter public
school, we are pleased to offer you a free educational choice.
Enclosed you will find a registration package. Completing the enclosed package will
confirm your child’s enrollment in César Chávez Academy.
This package contains very important documents, including permission forms,
medication notification and emergency procedure information. Please read these
forms carefully, complete them thoroughly and return this package to your academy.
We are pleased you have chosen our academy for your child and look forward to
working with you and your student to achieve educational excellence.
Gabriela Jaime
School Leader-CCA-LE
Kapeka VonKeltz
School Leader-CCAMS
Thomas Goodley
School Leader-CCA-UE
Juan José Martinez
School Leader-CCAHS
Javier Garibay
RVP-CCA District
Adasina Philyaw
School Leader-CCA-East
¡Si Se Puede!
Mission:
To provide a safe atmosphere of academic excellence that promotes
thinkers and problem solvers who work cooperatively and respectfully in an
inclusive environment.
Año escolar 2015-2016
Estimados Padres /Tutores:
Elementary (K-2)
8126 W. Vernor Hwy.
Detroit, MI 48209
Ph. # 313.843.9440
Fax # 313.297.6948
G. Jaime, Leader
Elementary (3-5)
4100 Martin
Detroit, MI 48210
Ph. # 313.361.1083
Fax # 313.361.1095
T. Goodley, Leader
Elementary (K-5)
4130 Maxwell
Detroit, MI 48214
Ph.# 313.924.0317
Fax # 313.924.0425
A. Philyaw, Leader
Middle School (6-8)
6782 Goldsmith
Detroit, MI 48209
Ph. # 313.842.0006
Fax # 313.842.0167
K. VonKeltz, Leader
High School (9-12)
1761 Waterman
Detroit, MI 48209
Ph. # 313.551.0611
Fax # 313.551.0552
J. Martinez, Leader
Gracias por matricular a su niño(a) en al Academia César Chávez. Como una escuela
publica ya establecida, nos da mucho gusto de ofrecerle una opción educacional gratis.
Incluido encontrara las formas necesarias para el registro. Completando estas formas
confirmara la matricula de su niño(a) en la Academia César Chávez. Este paquete
contiene documentos muy importantes; incluyendo la forma de permiso, notificación
médica e información de procedimiento de emergencia. Favor de leer las formas con
cuidado, completarlas y regresar el paquete a la academia.
Estamos complacidos que usted ha escogido a la Academia César Chávez para su niño(a)
y esperamos trabajar con usted y su niño(a) para lograr una educación con excelencia.
Gabriela Jaime
Directora -CCA-LE
Thomas Goodley
Director-CCA-UE
Kapeka VonKeltz
Directora-CCAMS
Juan José Martinez
Director-CCAHS
Javier Garibay
RVP-CCA Distrito
Adasina Philyaw
Directora-CCA-East
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
STUDENT REGISTRATION
STUDENT INFORMATION
Last name
First name
Address
Middle name
Apartment #
City of birth
Grade
Sex M or F
(circle one)
PREVIOUS SCHOOL INFORMATION
Name of last school attended
FAMILY INFORMATION
Father
State
Birth date
/
/
Dates attended
City
State
Last name
ZIP Code
First name
Employer
Step-parent
Yes or No
Guardian
Yes or No
Guardian
Yes or No
Name of other children in home
/
-
English proficient
Yes or No
Yes or No
check one
/
ZIP Code
Social Security #
/
/
Telephone number
School district in which parent or guardian lives
Mother
Student lives with
Parents
Father & stepmother
Home telephone
City
Other language spoken and/or read
Information on other children in home
Birth date
Daytime phone
Social Security #
Evening phone
Grade
Mother & stepfather
Mother only
Father only
Guardians
Court-appointed guardians
Foster parents
Signature of Parent/Guardian
FOR SCHOOL USE ONLY
Date enrolled
Student ID #
Date Enrolled
Date records requested
Date records received
U.S. Citizen? Yes or No
Copy of birth certificate?
Student ID #
Yes or No
Social Security card? Yes or No
Homeroom teacher
2 forms of proofs of residency? Yes or No
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
MATRICULA de ESTUDIANTE
INFORMACION DE ESTUDIANTE
Apellido
Nombre
Segundo Nombre
Dirección
Apartamento #
Ciudad de nacimiento
Grado
Sex o M or F
(marque una )
Información de Escuela anterior
Nombre de ultima escuela
Télefono
Ciudad
Estado
Codigo
/
/
Fecha que asistió
Ciudad
Estado
Fecha de nacimiento
-
/
Codigo Postal ______________
Seguro Social #
/
_________________
Telefono de la escuela
Distrito escolar donde viven los padres o tutotes
INFORMACION SOBRE LA FAMILIA
Competente en
Padre
Apellido
ingles
Si o No
Madre
Si o No
Padre
Si o No
Tutor
Si o No
Tutor
Si o No
Estudiante vive con:
Padres
Padre & Madrastra
/
/
Nombre
Empleador
Marque una
Nombres de estudiantes en la casa
Escribe y habla otro idoma
Información de los otros miembros de la familia
Fecha de nacimiento
Télefono de dia
Seguro Social
Télefono de noche
Grado
Mare & Padrastro
Madre solamente
Padre solamente
Tutores
Tutores asignados
Padres Adoptivos
Firma de Padre/tutor
FOR SCHOOL USE ONLY
Date enrolled
Student ID #
Fecha
Date records requested
Date records received
U.S. Citizen? Yes or No
Copy of birth certificate?
Student ID #
Yes or No
Social Security card? Yes or No
Homeroom teacher
2 forms of proofs of residency? Yes or No
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
EMERGENCY PROCEDURE CARD 2015-2016
Date of admission
Date of release
Child’s name (including last, first, middle initial)
Child’s address (including house number and street, building/apartment number)
Child’s date of birth
City
Home phone number
(
)
Grade
State
ZIP Code
Residency information
Student lives with (please circle one) parents, mother, father, stepmother, stepfather, other (explain):
Father’s/legal guardian’s name
Mother’s/legal guardian’s name
Home address (if not child’s address)
City
Home address (if not child’s address)
State
ZIP Code
City
State
ZIP Code
City
State
ZIP Code
Employer phone number
(
)
Hours of employment
a.m. to
Employer name
Employer name
Employer address
Employer address
City
State
ZIP Code
Employer phone number
(
)
Hours of employment
a.m. to
p.m.
Contact instructions
Please indicate whom we should contact in case of an emergency (other than parent):
1st choice:
Daytime phone:
Alternate phone:
Daytime phone:
Alternate phone:
Office phone:
Alternate phone:
(
(
(
(
(
(
)
)
)
)
)
)
Daytime phone:
Alternate phone:
Daytime phone:
Alternate phone:
If Yes, please explain.
(
(
(
(
)
)
)
)
2nd choice:
Doctor:
p.m.
Name(s) of person other than parent or legal guardian to whom child may be released:
Please indicate whom we should contact in case of an early dismissal (other than parent):
1st choice:
2nd choice:
Are there any restrictions on your child’s activities at school?
Yes or No
Is there any medical information/concern you would like to share with the school which might help better serve your child? This information is confidential.
In case of separated or divorced parents, are there any legal restrictions on the release of child to either parent? If so, provide a copy of formal documentation to
keep in your child’s file.
Emergency instructions
 I give permission to César Chávez Academy to secure emergency medical and/or surgical treatment for the above named minor child while in its care.
 I do not give permission to César Chávez Academy to secure emergency medical and/or surgical treatment for the above named minor child while in its care.
Hospital preferred in case of emergency:
Phone: (
)
Health insurance policy name and number:
Allergies:
Signature of Parent or Guardian:
Date
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
TARGETA DE EMERGENCIA 2015-2016
Fecha de Admición
Fecha de salida
Nombre del estudiante (apellido, primer, inicial)
Dirección (including house number and street, building/apartment number)
Fecha de nacimiento
Ciudad
Telefóno de casa
(
)
Grado
Estado
Informacion
Estudiante vive con: padres, madre, padre, madrastra, padrastro, otro (explicar):
Nombre de padre/tutor
Nombre de madre/tutor
Dirección (si no es dirección de su hijo(a) )
Dirección (si no es dirección de su hijo(a) )
Ciudad
Estado
Codigo Postal
Ciudad
Estado
Codigo Postal
Ciudad
Estado
Codigo Postal
Número del trabajo
(
)
Horario de empleo
a.m. to
p.m.
Nombre de Empleador
Nombre de Empleador
Dirección
Dirección
Ciudad
Estado
Codigo Postal
Número de trabajo
(
)
Hora de empleo
a.m. to
p.m.
Código Postal
Instrucciones
Favor de indicar a quien podemos hablar en caso de emergencia. Las personas que usted indique támbien se les permitirá liberan a su hijo(a):
Primera opción:
Telefóno: (
)
Celular: (
)
Segunda opción:
Telefóno: (
)
Celular: (
)
Doctor:
Telefóno de oficina: (
)
Otro numero: (
)
Nombres de otros personas que puede levnatar a su hijo(a):
Favor de indicar a quien puede llamar para levantar su hijo(a) en caso de un despido temprano (alguien que ademas de padres/tutores):
Primera opción:
Telefóno de dia (
)
Telefóno: (
)
Segunda opción:
Telefóno de dia: (
)
Telefóno: (
)
¿Hay alguna restriciones en las actividades de su hijo(a)? Si o No Si, por favor explicar.
¿Tienes alguna información medica/preocupación que le gustaria compartir con la escuela que la pueda ayudar?
En caso de una separación/divorcio, ¿ hay restricciónes en el despido de su hijo(a)? (Necesitamos una copia de documentos formales para el archivo de su
hijo(a).)
Instrucciones de emergencia
 Doy permiso a la Academia Primaria César Chávez para asegura tratamiento medico o quirúrjico a mi hijo(a) en caso de emergencia.
 No, doy permiso a la Academia Primaria César Chávez para asegurar tratamiento medico o quirúrjico a mi hijo(a) en caso de emergencia.
Hospital preferido en caso de emergencia:
teléfono: (
)
Numero de seguro medico y poliza:
Alergias:
Firma de los padre/tutor:
fecha
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
NATIONAL SCHOOL LUNCH PROGRAM NOTIFICATION
César Chávez Academy participates in the National School Lunch Program (NSLP). The
National School Lunch Program is a federally assisted meal program operating in public and
nonprofit private schools and residential child care institutions. It provides nutritionally balanced,
low-cost or free lunches to children each school day. The program was established under the
National School Lunch Act, signed by President Harry Truman in 1946.
To find out if your student qualifies for free or reduced lunch rates for the 2015-2016 school
year, please request the appropriate paperwork from César Chávez Academy office. Forms
and guidelines will be available after July 1, 2015.
FOR SCHOOL USE ONLY
Date of follow-up contact with parent to complete paperwork _______/_______/_______ (if registration packet completed before July 1, 2015)
Free and reduced lunch paperwork for the 2015-16 school year must be included with registration packets distributed after July 1, 2015.
Do not use paperwork from the 2015-16 school year.
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader- M. Tilton
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
NOTIFICACIÓN NACIONAL DEL PROGRAMA DEL ALMUERZO DE ESCUELA
La academia de César Chávez participa del programa nacional de almuerzo escolar
(NSLP). El programa nacional del almuerzo escolar es un programa de comida federal que
asiste a escuelas privadas, públicas y no lucrativas e instituciones residenciales de cuidado de
niños. Proporciona almuerzos nutricionales y balanceados, baratos o gratis a los niños durante
día de clase. El programa fue establecido bajo acto nacional del almuerzo de escuelas, firmado
por presidente Harry Truman en 1946.
Para verificar si su estudiante califica para las tarifas gratis o reducidas del almuerzo para el
año escolar 2015-2016, favor de solicitar una aplicación en la oficina de la academia de César
Chávez. Las formas y direcciones para completarlas estarán disponibles después del
1 de Julio, 2015.
FOR SCHOOL USE ONLY
Date of follow-up contact with parent to complete paperwork _______/_______/_______ (if registration packet completed before July 1, 2015)
Free and reduced lunch paperwork for the 2015-16 school year must be included with registration packets distributed after July 1, 2015. Do not use
paperwork from the 2015-16 school year.
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
INSTRUCTIONAL PHILOSOPHY
IDEA 97 states that, to the maximum extent appropriate, children with disabilities should be
educated with children who are not disabled. Special classes, separate schools or other
removal of children with disabilities from the regular educational environment should occur only
when the nature or severity of the disability of a child is such that education within regular
classes with the use of supplementary aids and services cannot be achieved satisfactorily.
César Chávez Academy embraces this philosophy, believing that special education students
can best be educated in the regular classroom. Our teachers accept responsibility for all
students in their classroom and modify, accommodate and adjust teaching techniques and
classroom activities to meet the learning abilities of all children.
Please indicate on the Special Education Records Request form in this registration packet if
your child has an Individual Education Plan in place. You will receive an invitation from the
intervention specialist or resource teacher to attend an IEP meeting, if necessary, within the first
month of your child’s enrollment at our academy.
The following signature indicates that I understand the instructional philosophy of the school.
Signature of Parent or Guardian
Date
The academy is participating in an effort to identify, locate and evaluate all children who may
have disabilities. For more information regarding assistance for students with disabilities or if
you suspect a child may have a disability, please contact the school leader.
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
FILOSOFÍA
La IDEA 97 indica eso, al grado máximo apropiado, los niños con discapacidades deben ser
educados con los niños que no son lisiados. Clases especiales, las escuelas separadas o el
otro retiro de niños con discapacidades del ambiente educativo regular deben ocurrir solamente
cuando la naturaleza o la severidad de la inhabilidad de un niño es tal que la educación dentro
de clases regulares con el uso de ayudas suplementarias y de servicios no se puede alcanzar
satisfactoriamente. La academia de César Chávez abraza esta filosofía, creyendo que los
estudiantes de educación especial pueden ser educados lo mejor posible en la salon de clases
regular. Nuestros profesores aceptan la responsabilidad de todos los estudiantes en su sala de
clase y se modifican, acomodan y ajustan las técnicas y las actividades de enseñanza de la
sala de clase para resolver las capacidades que aprenden de todos los niños.
Indique por favor en la forma de la solicitud de registro de educación especial en este paquete
del registro si su niño tiene un plan individual de educación en lugar. Usted recibirá una
invitación del especialista de la intervención o del profesor del recurso de asistir a una reunión
de IEP, en caso de necesidad, dentro del primer mes de la inscripción de su niño en nuestra
academia.
La firma siguiente indica que entiendo la filosofía educacional de la escuela.
Firma de padres/tutores
Fecha
La academia está participando en un esfuerzo de identificar, localice y evalúe a todos los niños
que puedan tener inhabilidades. Para más información con respecto a la ayuda para los
estudiantes con inhabilidades o si usted sospecha un niño puede tener una inhabilidad, entre
en contacto con por favor a líder de la escuela.
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924-0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
SPECIAL EDUCATION RECORDS REQUEST
□ My child has never received Special Education Services.
Signature of Parent or Guardian
Date
Please complete this form for all new students who were enrolled in special education at their previous school.
This request will then be forwarded to the special education department of your child’s previous school district.
Student name
Grade
Parent(s) name
Phone number
Address
City
Previous district attended
Date of birth
ZIP Code
Building
Address
City
ZIP Code
Disability
District contact person
Phone
Date of last Individual Education Plan
(please attach a copy)
□ Academic Records (Progress Report)
□ I.E.P.
□ Achievement Test Results
□ Health History
□ Medical Report
□ Psychological Evaluation & Test Results
□ M.E.T. Report
□ Social Work Report
□ Evaluation Review
□ Other
Please sign below so that we may request your child’s special education records, including all evaluation
reports, Multidisciplinary Team Reports and Individual Education Plans.
I grant permission for César Chávez Academy to receive the special education records of my
child
from
(please print name)
school district.
(please print name)
Signature of Parent or Guardian
FOR SCHOOL USE ONLY
Date form forwarded to special education teacher _______/_______/_______
Date records requested from previous school _______/_______/_______
Date records received from previous school _______/_______/_______
Date
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
School Leader-J. Martinez
AUTORIZACION PARA EXPEDIENTES DE EDUCACIÓN ESPECIAL
□ Mi nino(a) nunca hay recivido educación especial
Firma de padre/tutor
Fecha
Para estudiante de nuevo ingreso a la academia; que previamente recibía servicios de educación
especial.
Nombre del estudiante
Nombre de los padres/tutor
Grado
Fecha de nacimiento:
Número de teléfono:
Dirección:
Ciudad:
Distrito previo que asistió:
Edificio:
Código Postal:
Dirección:
Discapacidad:
Persona en contacto del distrito:
Número de teléfono:
Fecha de último IEP
(Favor de añadir una copia)
□ Academic Records (Progress Report)
□ I.E.P.
□ Achievement Test Results
□ Health History
□ Medical Report
□ Psychological Evaluation & Test Results
□ M.E.T. Report
□ Social Work Report
□ Evaluation Review
□ Other
Padres,
Favor de firmar abajo para solicitar el expediente de educación especial de su hijo (a).
Yo doy permiso a la academia César Chávez a que reciba el expediente de educación especial de mi hijo (a)
_ (escriba su nombre)
De
distrito escolar.
(escriba el nombre de la escuela anterior)
Firma de Padre/Tutor
FOR SCHOOL USE ONLY
Date form forwarded to special education teacher _______/_______/_______
Date records requested from previous school _______/_______/_______
Date records received from previous school _______/_______/_______
Fecha
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT (FERPA)
Please check the boxes of the items you would like to allow your child to participate in and sign
below.
 News information release
There may be times during the school year when the academy, The Leona Group, news media or
others wish to photograph or videotape your child at César Chávez Academy for use in print,
video, Internet or other communications methods.
I give my permission to César Chávez Academy to provide information concerning school
activities with my child to the general news media. I also give my permission for my child’s name,
portrait, picture or voice to be used for display or in promotional material in a variety of mediums
for the academy or its management company, The Leona Group, L.L.C., and/or in local media
coverage of academy events.
 Communication release
There may be times during the school year when the academy, The Leona Group or others wish
to identify your student by name and grade in newsletters, publications or yearbooks.
I give my permission to César Chávez Academy and its management company, The Leona
Group, L.L.C., to identify my child by name and grade in newsletters, publications or yearbooks.
 Artwork release
There may be times during the school year when the academy, The Leona Group, news media or
others wish to use artwork created by your child at the academy for use in print, video, Internet or
other communications methods.
I give my permission to César Chávez Academy to use artwork created by my child for
promotional purposes in a variety of mediums for the academy or its management company, The
Leona Group, L.L.C., and/or in local media coverage of academy events.
Student’s Name (please print)
Signature of Parent or Guardian
Date
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
DERECHOS EDUCATIVOS FAMILIARES Y ACTO DE PRIVACIDAD (FERPA)
Favor de marcar los artículos que usted quisiera permitir a su hijo(a) participar y luego firme la
forma.
 Autorización para liberar la información de las noticias
Pueden haber ocaciones durante el año escolar en que la academia, El grupo de Leona, los
medios u otros medios de noticias desean tomar foto o grabar a su niño en la academia de César
Chávez para el uso en la impresión, vídeo, Internet u otros métodos de las comunicaciones.
Doy mi permiso a la academia de César Chávez de proveer de la información referente a
actividades de la escuela mi niño a los medios de noticias generales. También doy mi permiso
para el nombre de mi niño, retrato, cuadro o voz que se utilizarán para la exhibición o en material
promocional en una variedad de medios para la academia o su compañía de gerencia, El grupo
de Leona, L.L.C., yo en la cobertura de medios local de los acontecimientos de la academia.
 Autorización para liberar medios de comunicación
Pueden haber ocaciones durante el año escolar en que la academia, El grupo de Leona u otros
deseen identificar su estudiante por nombre y grado en boletines de noticias, publicaciones o
anuarios.
Doy mi permiso a la academia de César Chávez y a su compañía de gerencia, El grupo de
Leona, L.L.C., para identificar mi niño por nombre y el grado en boletines de noticias,
publicaciones o anuarios.
 Autorización para liberar las ilustraciones
Pueden haber ocaciones durante el año escolar en que la academia, El grupo de Leona, medios
u otros medios de noticias que deseen utilizar las ilustraciones creadas por su niño en la
academia para el uso en la impresión, vídeo, Internet u otros métodos de las comunicaciones.
Doy mi permiso a la academia de César Chávez a las ilustraciones del uso creadas por mi niño
para los propósitos promocionales en una variedad de medios para la academia o su compañía
de gerencia, El grupo de Leona, L.L.C., yo en la cobertura de medios local de los acontecimientos
de la academia.
Nombre de estudiante
Firma de padre/tutor
Fecha
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
MEDICATION
Physicians may find it necessary to prescribe medication to be given during school hours. If your child is taking
any medication it must be dropped off at the school office by the parent, who must make arrangements with
the school to take this medication. Such medication must be in its original container and accompanied by the
physician’s written instructions, containing the following information:
1.
2.
3.
4.
Student’s name
Name of prescribing doctor
Name of medication
Instructions such as dosage and time to be given
Student’s name
Birth date
Name of medication
Diagnosis/purpose of medication
Form of medication Tablet/capsule  Liquid  Inhaler  Injection  Nebulizer  Other
Dosage
Frequency
Time
How is medication to be administered?
Should the school be aware of any adverse reactions or precautions?
Home phone
Doctor’s name
Emergency phone
Doctor’s phone
The undersigned parent/guardian authorizes César Chávez Academy through its administrators and/or staff to
administer medication or to supervise the taking of medication by my child.
It is understood that the undersigned parent/guardian shall immediately notify school personnel in writing in the
event the prescription shall be discontinued or modified. Refills of the prescription shall be the responsibility of
the parent/guardian.
Further, the undersigned shall release and indemnify César Chávez Academy and its employees from any
liability or damage which may result from the administration of said medication as prescribed by the physician.
Signature of Parent or Guardian
Date
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
MEDICAMENTOS
El medico puede encontrar necesario recetar medicina durante las horas escolares. Todo medicamento debe de estar en
un envase con tapa resistente a niños y el nombre de la persona que toma la medicina.
1.
2.
3.
4.
Nombre del estudiante
Nombre del doctor que resetó la medicina
Nombre del medicamento
Instrucciónes en cuando tomar el medicamento y la hora
Nombre del estudiante
Fecha de nacimiento
Nombre de medicamento
Forma de medicina
Diagnostico/propósito del medicamento
Tableta/capsula
Dosis
Líquido
Inhalador
Injección
Frecuencia
Nebulizador
Other
Hora
¿Como se debe dar el medicamento?
¿Debería de estar alerta la escuela de alguna reacción ó precaución?
El padre ó tutor asignado autoriza a la Academia Secundaria César Chávez y al personal para administrar el
medicamento y supervisar al estudiante al tomar la medicamento.
Esta entendido que el padre ó tutor asignado debe de notificar al personal de la escuela inmediatamente descontinuado ó
modificado. El padre ó tutor tiene la responsabilidad de re-llenar la receta.
Además, el asignado debe identificar a los empleados de la Academia Primaria César Chávez de algún daño ó que
puede resultar de la administración de dicha medicina que a recetado el doctor.
Firma de padres/tutor
Número de teléfono
Número en caso de emergencia
Nombre del doctor
Numero de teléfono para doctor
Fecha
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
IMMUNIZATION
State law prohibits a principal or teacher from admitting new entrants to school without a record of having received at least one dose of
each: Measles, Mumps, Rubella, Polio, Diphtheria, Tetanus, Pertussis, Hepatitis B, and Chickenpox (Varicella). Children who have not
received the required immunizations will be excluded from school until parents provide proof that all required immunizations have been
received or until the school has a waiver on file.
Immunization schedule
Ages 4 – 6
Immunization
Diphtheria, Tetanus
and Pertussis
Polio
Measles, Mumps
and Rubella
Hepatitis B
Varicella
(Chickenpox)
Ages 7-18
4 doses are required. If a dose was not given on or after the 4th
4 doses are required.
birthday, a booster dose of DTP is required. Most children will have 5
doses.
3 doses are required. If the last dose was not given on or after 4th
3 doses are required.
birthday, a booster dose is required. Most children will have 4 doses.
st
2 doses are required. The 1st dose must be given on or after the 1
2 doses are required. The 1st dose must be given on or after the 1st
birthday. The 2nd dose must be given at least 28 days from the 1st
birthday. The 2nd dose must be given at least 28 days from the 1st
dose.
dose.
3 doses are required. Minimum of 28 days between 1st and 2nd doses; minimum of 56 days between 2nd and 3rd doses; minimum of 4 months
between 1st and 3rd doses; and 3rd dose must be administered on or after 24 weeks or 168 days of age.
1 dose required if received on or after the 1st birthday but prior to the
1 dose required on or after 1st birthday.
13th birthday OR 2 doses required, administered at least 28 days apart, if
the child received the 1st dose on or after the 13th birthday.
Immunization waiver
A parent or guardian wishing to exempt his/her child from a particular vaccination must provide a written statement indicating the
religious or philosophical objections to the vaccination(s). A child who has been exempted from a vaccination is considered susceptible
to the disease or diseases for which the vaccination offers protection. That child will be subject to exclusion from the school or program
if an outbreak of a vaccine-preventable disease to which s/he is susceptible occurs.
By signing this waiver, you acknowledge that you are placing your child and others at risk of serious illness should s/he contract a
disease that could have been prevented through proper vaccination.
I object to having my child immunized against the diseases I have checked below:
 Diphtheria
 Pertussis
 Measles
 Rubella

Tetanus

Polio

Mumps

Hepatitis B


Reason:
Student’s Name (please print)
Signature of Parent or Guardian
Date
Varicella (Chickenpox)
Other
_______________________
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
VACUNAS
La ley del estado prohíbe a un director o a profesor de admitir principiantes nuevos a la escuela sin un expediente de recibir por lo
menos una dosis de cada uno: Sarampión, Paperas, Sarampión, Poliomielitis, Difteria, Tétanos, Pertussis, Hepatitis B, y varicela
(varicela). Excluirán a los niños que no han recibido las inmunizaciones requeridas de escuela hasta que los padres proporcionan la
prueba que se han recibido todas las inmunizaciones requeridas o hasta que la escuela tiene una renuncia en expediente.
Requisitos de Vacunación
Edades 4 – 6
Vacunación
Difteria, Tétanos y
Pertussis
Polio
Sarampión,
Paperas y
sarampión
hepatitis femenino
Varicela
(Chickenpox)
Edades 7-18
requieren 4 dosis. Si una dosis no fue dada en o después del 4to
cumpleaños, una dosis de aumentador de presión del DTP se requiere.
se requieren 4 dosis
La mayoría de los niños tendrán 5 dosis.
requieren 3 dosis. Si la dosis pasada no fue dada en o después del 4to
cumpleaños, se requiere una dosis de aumentador de presión. La
se requieren 3 dosis
mayoría de los niños tendrán 4 dosis.
requieren 2 dosis. La 1ra dosis se debe dar en o después del 1r
se requieren 2 dosis. La 1ra dosis se debe dar en o después del 1r
cumpleaños. La 2da dosis se debe dar por lo menos 28 días de la 1ra
cumpleaños. La 2da dosis se debe dar por lo menos 28 días de la 1ra
dosis.
dosis.
requieren 3 dosis. Mínimo de 28 días entre las 1ras y 2das dosis; mínimo de 56 días entre las 2das y 3ro dosis; mínimo de 4 meses entre las 1ras
y 3ro dosis; y la 3ro dosis se debe administrar en o después de 24 semanas o de 168 días de la edad.
1 dosis requirió si está recibida en o después del 1r cumpleaños pero
antes del décimotercero cumpleaños O de 2 dosis requeridas,
1 dosis requerida en o después del 1er cumpleaños.
administrado por lo menos 28 días aparte, si el niño recibió la 1ra dosis
en o después del décimotercero cumpleaños.
Immunization waiver
Un padre o un tutor que desea renunciar a las vacunas de su niño (a) debe proporcionar una declaración escrita que indica las
objeciones religiosas o filosóficas a las vacunaciones. Consideran a un niño que se ha eximido de una vacunación susceptible a la
enfermedad o a las enfermedades para las cuales la vacunación ofrece la protección. Ese niño estará conforme a la exclusión de la
escuela o programará si un brote de una enfermedad evitable con la vacuna lo convierte susceptible.
Firmando esta renuncia, usted reconoce que usted está predisponiendo a su niño (a) a riesgo de enfermedades serias si sé contrae
una enfermedad que se habría podido prevenir con la vacunación apropiada.
Yo, rehuso a que mi niño(a) reciba vacunas para prevenir las enfermedades que he marcado:

Difteria

Pertussis

Sarampión

Anti-sarampión

Varicela (Chickenpox)

Tétanos

Polio

Paperas

Hepatitis B

Other _______________________
razón:
Nombre de estudiante (escriba su nombre)
Firma de padre/tutor
Fecha
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
INTERNET ACCEPTABLE USE POLICY
Prior to receiving authorization to use the Internet, students and their parents/guardians must sign the following
permission and contract document.
Parents
I give permission for my child to participate in the use of the Internet, a worldwide telecommunications network.
I realize that (s)he will be able to access major networks throughout the world using the Internet. I understand
that this access is designed and intended for educational purposes only. I also understand that the student will
receive instruction in the appropriate use of this resource.
I realize the Internet contains material that is inappropriate for school purposes. I support the school’s position
that students are responsible for not accessing such material. Such unacceptable use of the network will result
in the suspension of all privileges. I will not hold César Chávez Academy accountable for unsuitable materials
acquired by the student through Internet usage for school.
I acknowledge that I have read the Internet Acceptable Use Policy.
Student’s Name (please print)
Signature of Parent or Guardian
Date
Students
I will abide by the Internet Acceptable Use Policy. I understand that the Internet contains material inappropriate
for school use and, therefore, will take personal responsibility not to access this material. I recognize that it is
impossible for César Chávez Academy to prevent access to all controversial materials, and I will not hold them
responsible for materials found or acquired on the network. I further understand that any violation of the
regulations in this policy is unethical and may constitute a criminal offense. Should I commit any violation, my
access privileges may be revoked and appropriate school discipline and/or legal action may be taken.
Student’s Name (please print)
Grade
Student’s Signature
Date
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
POLIZA PARA EL USO DEL INTERNET
Antes de recibir la autorización de utilizar el Internet, estudiantes y sus padres /tutor deberán firmar el
siguiente documento y contrato de permiso
Padres
Doy permiso para que mi niño(a) participe en el uso del Internet, una red mundial de telecomunicaciones.
Entiendo que mi hijo(a) podrá tener acceso a redes importantes a través del mundo usando el Internet.
Entiendo que este acceso está diseñado y proyectada solamente para propósitos educativos. También
entiendo que el estudiante recibirá la instrucción para el uso apropiado de este recurso.
Comprendo que el Internet contiene material que es inadecuado para los propósitos de la escuela. Apoyo la
posición de la escuela que los estudiantes sean responsables a no tener acceso a tal material. Tal uso de red
será inaceptable y dará lugar a la suspensión de todos los privilegios. Yo no sostendré responsable a la
academia César Chávez de materiales inadecuados adquiridos por el mi hijo(a) en el uso del Internet en la
escuela.
Reconozco que he leído la póliza del Internet.
Nombre de estudiante (letra de molde)
Firma de padre/tutor
Fecha
Estudiantes
Seguiré la Póliza del Internet. Entiendo que el Internet contiene inadecuado material para el uso de la escuela
y, por lo tanto, tomaré la responsabilidad personalmente de no tener acceso a este material. Reconozco que
es imposible que la academia César Chávez prevenga el acceso a todos los materiales polémicos, y no los
sostendré responsables de los materiales encontrados o adquiridos en la red. Entiendo que cualquier violación
a las regulaciones de esta póliza es poco ética y puede constituir una ofensa criminal. Si cometo alguna
violación, mis privilegios al acceso del Internet pueden ser revocados y disciplina apropiada por la escuela /y o
acción legal puede ser tomada.
Nombre de estudiante
Grado
Firma de padre/tutor
Fecha
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
AFFIRMATION OF PRIOR DISCIPLINE RECORD
Check the appropriate box, provide all appropriate information and sign this document.
I affirm that the information provided here is true and that any false statement may result in forfeiting my child’s
enrollment privileges at César Chávez Academy.
 The undersigned affirms that
has not been suspended or expelled from any school.
 The undersigned affirms that
has been suspended or expelled from a school.
If the student has been suspended or expelled, please provide the school name, date of suspension and/or expulsion,
along with a detailed description of the incident(s).
Signature of Parent or Guardian
Date
Signature of César Cávez Academy Staff Member
Date copy sent for verification
Former school district
Name and address of responding school district:
City
State
ZIP Code
(
)
Phone number
Please check one:
 According to our records, we verify that the information provided above by the parent/student is correct.
 According to our records, the information provided above by the parent/student is not correct. Appropriate
documentation of suspensions and/or expulsions is attached.
Signature and title of sending district administrator
Date
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
AFIRMACIÓN DEL EXPEDIENTE ANTERIOR DE DISCIPLINA
Marque la caja apropiada, proporcione toda la información necesaria y firme este documento.
Afirmo que la información proporcionada aquí es verídica y que cualquier declaración falsa puede dar lugar a
perder los privilegios de la inscripción de mi niño en la academia de César Chávez.
 Mi niño(a)
no ha sido suspendido o expulsado de ninguna escuela.
 Mi niño (a)
ha sido suspendido o expulsado de la escuela.
Si su niño(a) ha sido suspendido o ha sido expulsado, favor de proporcionar el nombre de la escuela, fecha de la
suspensión y/o expulsión, junto con una descripción detallada de los incidentes.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Firma de padre/tutor
Fecha
Firma del Personal
fecha de verificación enviada
Distrito Escolar Previo
Nombre y dirección del distrito escolar:
Ciudad
Estado
Código Postal
(
)
Número de Teléfono
Favor de marcar uno:
 Según nuestros expedientes, verificamos que la información proporcionada arriba por el padre del estudiante está
correcta.
 Según nuestros expedientes, la información proporcionada por el padre del estudiante no es correcta. Adjunto
encontrara la documentación apropiada para suspensiones o expulsión las expulsiones.
Firma de un empleo de la escuela
Fecha
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
HOME LANGUAGE SURVEY
Date
Date of Birth
Student name (last, first, middle initial)
Address (including house number and street, building/apartment number)
Home #
(
)
City
Cell #
(
)
Grade
State
Parent/Guardian's name
1.
What was the first language your child learned?
2.
What languages, other than English, are spoken in the home?
3.
What language is spoken most often by your child?
4.
Was your child receiving help with English in their previous school?
Comments
Signature of Parent or Guardian
Date
Zip Code
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
ENCUESTA de IDIOMA
Fecha
Fecha de nacimiento
Nombre del estudiante (apellido, primer, inicial)
Dirección (including house number and street, building/apartment number)
Telefóno de casa
(
)
Ciudad
Cellular
(
)
Grado
Estado
Nombre de los padres
1.
¿Cual fue el primer lenguaje que su hijo(a) aprendió?
2.
¿Cual otros lenguaje además de ingles habla su hijo(a) en la casa?
3.
¿Cual es el lenguaje que su hijo(a) habla con mas frecuencia?
4.
¿Recibió su hijo(a) ayuda con ingles en su escuela previa?
Comentarios:
Firma de padre/tutor
Fecha
Código Postal
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
ETHNICITY FORM
Date
Grade
Child’s name (including last, first, middle initial)
Home phone number
(
)
Child’s date of birth
Cell number
(
)
Year of entry into the US
Race and Ethnicity: (Note: Both Part A and Part B of the question must be answered.)
Part A: Is this student Hispanic/Latino? (Choose only one)
o
No, not Hispanic/Latino
o
Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, Cuban, South or Central
American, or other Spanish culture or origin, regardless of race.)
The above part of the question is about ethnicity, not race. No matter which box you selected above, please continue to
answer the following by marking one or more boxes to indicate what you consider your student’s race to be.
Part B: What is the student’s race? (Choose one or more)
o
American Indian or Alaska Native (A person having origins in any of the original peoples of
North and South American, including Central America).
o
Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the
Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia,
Pakistan, the Philippine Islands, Thailand and Vietnam.)
o
Black or African American (A person having origins in any of the black racial groups of Africa.)
o
Native Hawaiian or Other Pacific Islander (A person having origins in any of the original
people of Hawaii, Guam, Samoa or other Pacific Islands.)
o
White (A person having origins in any of the original peoples of Europe, the Middle East or North
Africa.)
NOTE: Both parts A and B MUST be completed. We encourage you to select an answer for both parts. If either part (A or
B) is not answered, the U.S. Department of Education requires the school district to supply an answer on your
behalf.
Person Completing this form (please print)___________________________________________________
Parent/Guardian Signature:_______________________________________ Date ___________________
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
FORMULARIO DE ORIGEN ETNICO
Fecha
Grado
Nombre de estudiante (incluir apellido primer nombre e inicial))
Fecha de nacimiento
Numero de casa
(
)
Año de entrada en los Estados Unidos
celular
(
)
La raza y el origen étnico: (Nota: la Parte A e Parte B de la preguntas deben ser contestadas)
Parte A: El estudiante es hispano/latino? (por favor elija uno)
o
No, no es hispano/latino
o
Si, es hispano/latino ( Una persona Cubana, Mexicana, Puerto Riqueña, o del Sur o Centro América o cualquier
otra cultura Hispana, independientemente de su raza)
La parte de arriba de la pregunta es sobre el origen étnico, no raza. No importa el cuadro que ha seleccionado
anteriormente, por favor conteste lo siguiente, marcando una o mas cajas para indicar lo que usted considere es la
raza de su hijo/a.
Parte B: Cual es la raza del estudiante? (elija uno o mas)
Indio Americano o Nativo de Alaska (Una persona con orígenes en cualquiera de los pueblos originarios de
Norte y Sur América, incluyendo América Central).
Asiático (Una persona con orígenes en cualquiera de los pueblos originales del Lejano Oriente, el sudeste de Asia, o el
Subcontinente indio, incluyendo, por ejemplo, Camboya, China, India, Japón, Corea, Malasia,
Pakistán, las Islas Filipinas, Tailandia y Vietnam.)
o Negro o Afro Americano ( Una persona que tiene sus orígenes en cualquier grupo racial negro de Africa)
o
Nativo de Hawái u otra Isla del Pacifico (Una persona que tiene orígenes en cualquiera de los grupos
originales de Hawái, Guam, Samoa, u otras Islas del Pacifico.
o
Blanco ( Una persona que tiene orígenes en cualquiera de los grupos de personas originales de Europa, Medio
este o Norte de África)
NOTA Las dos partes A y B DEBEN estar completas. Lo animamos a que elija una respuesta par alas DOS partes. Sea
la Parte A o B . Si no responde, el Departamento de Educación requiere que el distrito escolar provea una respuesta en
su nombre.
Persona completando la forma (por favor imprima):______________________________________________
Firma del padre/tutor:_______________________________________ Fecha___________________
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
STUDENT RESIDENCY
By completing this questionnaire, you help the school comply with the McKinney-Vento Act, Title X, Part C of
the No Child Left Behind Act. Your truthful and accurate answers help the school identify services that the
student may be eligible to receive.
Date
Student Age
Sex
Grade
o
o
Male
Female
Student name (last, first, middle initial)
Address (including house number and street, building/apartment number)
Home #
(
)
City
Cell #
(
)
State
Zip Code
Parent/Guardian's name
1. Where is the child living now? (check one box)
□ In a shelter
□ In a car
□ In a motel or hotel
□ In a trailer park or campsite
□ With more than one family in a house or apartment
□ With friends or family members other than parent or guardian
□ None of the above
If you checked the box marked “None of the above” you do not have to complete the remainder of this form.
Please sign below and return a copy of this form to the school office.
2. Does the living arrangement marked in Question 1 result from a loss of housing or economic hardship?
□ Yes □ No
□ Unsure
3. Who does the child live with?
□ 1 parent
□ 2 parents
□ 1 parent and another adult
□ a relative, friend(s) or other adult(s)
□ alone with no adults
□ an adult who is not the parent or legal guardian
Signature of Parent or Guardian
Date
FOR SCHOOL USE ONLY
□ Student not covered by McKinney-Vento Act
□ Student covered by McKinney-Vento Act
□ Follow-up required
Contact person at the student’s school who may know of the family situation:
Name
Phone number
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
RESIDENCIA DE ESTUDIANTE
Completando este cuestionario, usted ayuda a la escuela a llevar acabo el acto de McKinney-Vento, y el
reglamento de “ningún niño se quede atrás. Su sinceridad y respuestas exactas a ayudara a la escuela a
identificar los servicios que el estudiante puede ser elegible a recibir.
Fecha
Fecha de nacimiento
Sexo
o
o
Hombre
Mujer
Grado
Nombre del estudiante (apellido, primer, inicial)
Dirección (including house number and street, building/apartment number)
Telefóno de casa
(
)
Ciudad
Cellular
(
)
Estado
Código Postal
Nombre de los padres
1. ¿Donde vive el estudiante ahora? (Marque una)
□ en un refugio
□ en un carro
□ en un motel o hotel
□ en un parque o sitio para acampar del acoplado
□ Con más de un familiar en una casa o apartamento
□ Con amigo(s) o familia que no son padres o tutor
□ Ninguna de las antes mencionadas
Si usted marcó la caja “ninguno de las antes mencionadas” usted no tiene que terminar el resto de esta forma.
Favor de firmar y regrese esta forma a la oficina de la escuela.
2. ¿Para los arreglos de vivienda que marco en la pregunta numero 1, fue por la perdida
por dificultad económica?
□ Si
□ No
□ No se
3. ¿Con quien vive el estudiante?
□ 1 padre
□ 2 padres
□ 1 padre y otro adulto
□ Familia, amigo(s) u otro adulto(s)
□ Sin adultos
□ Un adulto que no es un padre o tutor
Firma de padre/tutor__________________________________________________
Fecha____________________
FOR SCHOOL USE ONLY
□ Student not covered by McKinney-Vento Act
□ Student covered by McKinney-Vento Act
□ Follow-up required
Contact person at the student’s school who may know of the family situation:
Name
Phone number
de su vivienda o
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
FAMILY FEEDBACK
/
Date
(month)
/
(day)
(year)
Thank you for choosing César Chávez Academy. We are committed to serving our families in a pleasant and courteous manner. Please
take a few minutes to complete this brief questionnaire. Your feedback is very important and your responses will be kept confidential.
How did you hear about César Chávez Academy?
 Newspaper ad
 Radio commercial
 Newspaper article
 Television commercial
 Web site
 Movie theater commercial
 Flier
 Postcard in mail
 Friend or relative
 Saw building or sign
 Other:
________________
Customer service
If you called for information, was the call answered promptly in a friendly and courteous manner?
 Yes
 No, please explain: _____________________________________________________________________________________
If you requested information via the school Web site, was your request answered promptly in a friendly and courteous manner?
 Yes
 No, please explain: _____________________________________________________________________________________
If you visited the school for information, were you greeted promptly in a friendly and courteous manner?
 Yes
 No, please explain: _____________________________________________________________________________________
Were all of your questions regarding César Chávez Academy answered to your satisfaction?
 Yes
 No, please explain: _____________________________________________________________________________________
In your words
What words would you use to describe the school building and grounds?
 Clean

 Safe and secure
 Outdated, old
Accessible
 Inviting

 Unclean
 Unorganized
School pride displayed
 Modern

 Building, classrooms and office well-marked with signs
Colorful
What words would you use to describe the school Web site?
 Easy to use

Quality
 Informative

Up-to-date information
 School pride shown

Relevant information
 Appealing
 Out-of-date information
 Confusing
What words would you use to describe school advertising you saw?
 Quality

Interesting
 Original

Relevant
 Professional

To the point
 Not relevant
 Misleading
 Confusing
 Didn’t stand out
 Not representative of school, students or community
 Not attractive
 Difficult to use
 Too much information
What words would you use to describe why you and your child chose César Chávez Academy?
 Quality education

 Family-oriented
 Curriculum focus
Safe, secure building
 Caring staff

 Good reputation
 Diverse student body
Transportation
 Small school atmosphere

 Best option available
 No other choice
Uniforms
 Close to my home

 Attention given to student and family needs
School leader
Other comments
Please use this area to share any other comments you have.
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
OPINION FAMILIAR
/
Fecha
(Mes)
/
(DIA)
(año)
Gracias por elegir la academia de César Chávez. Nuestra misión es servir a nuestras familias de una manera cortes y agradable.
Por favor tome unos minutos para completar este breve cuestionario. Su opinión es muy importante y sus respuestas se mantendrán
confidenciales.
¿Cómo se entero de la academia de César Chávez?
 periódico
 Television
 sitio de red
 cine
 Radio
 folleto
 tarjeta postal
 amigo o familia
 Billboard o anuncio
 otro:
 ________________
Servicios
Si usted llamó para información ¿Fue su llamada contestada puntualmente de manera amistosa y cortes?
 Si
 No, favor explicar: __________________________________________________________________________________
Si usted solicitó información vía la red de comunicación de la escuela, ¿Fue su petición contestada puntualmente de manera amistosa
y cortes?
 Si
 No, favor explicar: __________________________________________________________________________________
Si usted visitó la escuela para información, ¿Le saludaron puntualmente de una manera amistosa y cortes?
 Si
 No, favor explicar: __________________________________________________________________________________
¿Todas las preguntas relacionadas con la academia César Chávez le fueron contestada a su satisfactoriamente?
 Si
 No, favor explicar: __________________________________________________________________________________
En sus palabras
¿Qué palabras utilizarían usted para describir el edificio y el terreno de la escuela?
 limpio

 seguridad
accesible
 Acogedor

 sucio
Respecto de la escuela
 moderno


lleno de colores
 anticuado, viejo

¿Qué palabras utilizarían usted para describir la página de red de la escuela?
 Facil de usar

 atractivo
calidad
 informativo

 Informacion vieja
Informacion nuevo
 Respecto de la escuela

 confuso
Información pertinente
 atractivo
 Dificil para usar
 mucho informacion
¿Qué palabras utilizarían usted para describir el anuncio de la escuela?
 calidad

 No es pertinente
Interesting
 Original

 confuso
pertinente
 profesional


específica
 engañoso

¿Qué palabras usted utilizarían describir el porqué usted y su niño eligió la academia César Chávez?
 Educacion con calidad

 Ambiente Familiar

seguridad
 Empleados Amigables

 Buen reputation

transporte
 Escuela pequena

 Best option available

Uniformes
 Cerca de mi casa


Director
Otros commentarios
Por favor utilice esta área para compartir cualquier otro comentario que usted tenga.
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
CÉSAR CHÁVEZ ACADEMY PLEDGE
I,
, parent of
,
support the mission and educational goals of César Chávez Academy
I resolve to show that I am an interested and responsible parent:
1. I will send my child to school every day ready to learn
2. I will send my child to school every day healthy, clean and well-cared for
3. I will teach my child to be well-behaved and show good manners
4. I will notified the school when my child is ill or is going to be absent
5. I will teach my child to respect all property and to take care of all school, supplies, books,
and equipment
6. I will attend conferences about my child
7. I will support the school and my child’s teacher in helping my child follow the code of
conduct
8. I will volunteer to work with my child’s teacher in school or at home
Student’s Name
Signature of Parent or Guardian
Date
CCA Elementary
Vernor Campus
Grades K-2
8126 Vernor Hwy.
Detroit, MI 48209
313.843.9440
Fax
313.297.6948
School Leader-G. Jaime
CCA-Intermediate
Martin Campus
Grades 3-5
4100 Martin
Detroit, MI 48210
313.361.1083
Fax
313.361.1095
School Leader-T. Goodley
CCA-Elementary
East Campus
Grades K-5
4130 Maxwell
Detroit, MI 48214
313.924.0317
Fax
313.924.0425
School Leader-A. Philyaw
CCA-Middle School
Waterman Campus
Grades 6-8
6782 Goldsmith
Detroit, MI 48209
313.842.0006
Fax
313.842.0167
School Leader-K. VonKeltz
CCA-High School
Waterman Campus
Grades 9-12
1761 Waterman
Detroit, MI 48209
313.551.0611
Fax
313.551.0552
School Leader-J. Martinez
PROMESA
Yo, _____________________________________, el padre de ______________________,
sostengo la misión y las metas educativas de la Academia Primaria César Chávez.
Yo me comprometo a mostrar que soy un padre interesado y responsable:
1. Mandaré a mi niño(a) cada día a la escuela preparado para aprender.
2. Mandaré a mi niño(a) cada día a la escuela saludable, limpio y bien cuidado.
3. Enseñaré a mi niño(a) a ser educado y mostrar buenos modales.
4. Notificaré a la escuela cuando mi niño(a) este enfermo.
5. Enseñare a mi niño(a) a respetar toda propiedad y a cuidar todos los artículos escolares,
libros u equipo de la escuela.
6. Asistiré a las conferencias con respecto a mi niño(a).
7. Ayudare a la escuela y al maestro de mi niño(a) en ayudar a mi niño(a) a cumplir con el
código de conducta.
8. Me ofreceré a ser voluntaria(o) a trabajar con el maestro(a) de mi niño(a) en la escuela o
en la casa.
Nombre del Estudiante (letra de molde)
Firma del Padre o Tutor
Fecha