Welcome to Nevada Connections Academy!

Thank you for selecting a high quality, personalized education for your child through Nevada Connections Academy. The
enclosed materials will help you get started with the enrollment process. Please complete, sign, and return the enclosed
forms along with the cover page. Then, take the next step by logging in to Connexus®.

Log in to Connexus today—and often!

 Connexus is the online system used to enroll and take classes.
 Visit Connexus.com and enter your username and password.
 Lost your login info? Call 1-800-382-6010 for help!

If you prefer, you can complete most of the enrollment and placement process online. Connexus has everything
you need, including this entire package.

What can you do in Connexus?

 Complete the Parent/Legal Guardian (Caretaker) Acknowledgement, the Student Information form, and the
Family Information form online. These forms help us determine how to best meet your family’s needs and help us
identify any additional documents you may need to submit.
 View a list of items you need to submit and the status of previously-submitted items.
 Check on your student’s progress toward enrollment.
 Confirm your student’s courses.
 Verify your shipping address to ensure the prompt arrival of any applicable course materials.
 Complete the confirmation of your student’s intent to start school.

Once you have completed the confirmation, we will ship any applicable materials to the address you provided, and your
student will be ready to learn with us!

Want to learn more?

Visit the Connections Academy website to attend an information session, to connect with other Connections Academy
parents, and to read more about our school.

If you require or prefer accessible documents, a complete set is available and can be completed online.
Visit www.Connexus.com.

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 2018–19 NCA Document Cover Page
Use this Document Cover Page whenever you submit documents. Check the box next to each item you are submitting. If sending
documents for more than one student, group items per student and include a separate Document Cover Page for each student.
Submit enrollment documents to Connections Academy by: Scan and upload documents in Connexus® | Fax: 800-887-6590
rd
Mail: 10960 Grantchester Way 3 Floor, Columbia, MD 21044

Student
Last Name: ________________________________________ First Name: _________________________________________
Middle Name: _____________________________________ Date of Birth: _________________________________________

Parent/Legal Guardian
Last Name: ________________________________________ First Name: _________________________________________
Middle Name: _____________________________ Number of pages, including this cover: _________ Date sent: ___________

Required Items
Check which items you are sending now:
Proof of Residency – Provide a copy of one of the following items showing your name and service address (for the purpose of
shipping your educational materials to the correct address): gas, electric, cable, phone, internet, sewage, or water bill from the
last 60 days OR mortgage statement OR signed and current lease agreement OR recent rent receipt OR letter from
government agency OR driver’s license. Disconnection Notices are not acceptable proof of residency.
Proof of Age – Provide a copy of one of the following items: student’s official birth certificate OR passport OR military ID OR
student driver’s license OR tribal affiliation OR green card.
Proof of Immunization – Provide a copy of one of the following items, stamped or signed by a health care provider: booklet
obtained from your health care provider OR health care provider/department printout OR school record OR Immunization
Record/Statement of Exemption we have provided.

Conditionally Required Enrollment Items

Sending Now Not Applicable
OR Family Income Form – Send one form per family.
OR Custodial Documentation or Court Order – Send if custody is determined by court, state agency, or
separation agreement.

Requested Academic Placement Documentation

Sending Now Not Applicable

OR Report Card or Unofficial Transcript
OR Home School Prior Academic History
OR Gifted and Talented Documentation (required if student is requesting placement into a gifted course)
OR Individualized Education Program (IEP) (or formal exit documentation, if services were discontinued)
OR Evaluation Documentation
OR 504 Plan
OR State Test Scores
OR Additional Placement Documents – Check all that apply:
Progress Reports Course Summaries Class Schedules Skills Assessment(s) Grading Scale

Please note that open Enrollment in Nevada Connections Academy for the 2018-19 school year ends in September 2018.
After the deadline, students are enrolled by a lottery as openings become available.

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 NCA Immunization Record/Statement of Exemption
Form Facts
Use this form to obtain immunization information for a student from his or her health care provider or to provide a statement of exemption if no other
immunization record or statement of exemption document is available. A valid proof of immunization or exemption statement must be submitted for
each enrolling student to comply with state regulations. A health care provider’s signature is required if you provide immunization information or a
medical statement of exemption using this form. Check the Document Cover Page or log in to Connexus® for a list of the acceptable proofs of
immunization.
Submit items to Connections Academy by: Scan and upload in Connexus® (www.connexus.com) | Fax: 800-887-6590
Mail: 10960 Grantchester Way 3rd Floor, Columbia, MD 21044

Student Information
Name (Last, First Middle): ___________________________________________________________________________ Gender: Male Female

Current Grade: _______________________________ Date of Birth: ___________________________________________

Known allergies or reactions to vaccines:________________________________________________________________________________________

Immunizations – A Health Care Provider Must Complete This Section

This section must be completed by a health care provider (physician, health official, school nurse, or designee of one of these providers). Instructions to
health care provider: Indicate the dates you or another provider gave the patient the Vaccine Information Statement (VIS) and administered the dose.

Vaccine Dose 1 Dose 2 Dose 3 Dose 4 Dose 5 Dose 6

DTaP/DTP/DT/Td Diphtheria, Tetanus, and Pertussis
Tdap Booster Tetanus, Diphtheria and Pertussis
OPV/IPV Polio
HepB Hepatitis B
HepA Hepatitis A
MMR Measles, Mumps, Rubella
Varicella Chickenpox Has had chickenpox – no doses needed
PCV Pneumococcal Conjugate Vaccine
Td Booster Tetanus Booster
Hib Haemophilus Influenza Type b
HPV Human Papillomavirus
ROTA Rotavirus
TST Tuberculin Skin Test
MCV Meningococcal Vaccine
Influenza Influenza
To the best of my knowledge, this student has received the required immunizations for the state of __________________________________________

Health Care Provider’s Information

Name (Last, First Middle): ___________________________________________________________ Phone: ________________________________
Health Care Provider’s Signature: _____________________________________________________ Date: _________________________________
Street Address: ____________________________________________________________________________________________________________
City: ________________________________________________________________ State: _______________________ Zip Code: _______________

Statement of Exemption – Use This Section ONLY If Claiming Exemption

MEDICAL EXEMPTION – The physical condition of the above-named student is such that immunization would endanger the student’s life or health. The
student is exempt from the immunizations specified above due to his or her condition. If a medical exemption is necessary for an individual vaccine or dose,
please write “Exempt” in the appropriate field(s) above.
Health Care Provider’s Name (Last, First Middle): ________________________________________________ Phone: _________________________

Health Care Provider’s Signature: _______________________________________________________________ Date: _________________________

RELIGIOUS EXEMPTION – I, the parent/legal guardian of the above named student, am adherent to a religious belief whose teachings are opposed
to such immunizations.

Parent/Legal Guardian’s Name (Last, First Middle): _______________________________________________ Phone: _________________________

Please print and sign.

Parent/Legal Guardian’s Signature: ______________________________________________________________ Date: _________________________

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