Bales Elementary Buckeye Elementary Inca Elementary · Buckeye Elementary School District (BESD) will be participating in the National School Lunch Program and the School Breakfast

Wednesday Wednesday Wednesday8:30 am to 1:45 pm 8:30 am to 1:45 pm 8:00 am to 1:15 pm

Monday, Tuesday, Thursday, Friday Monday, Tuesday, Thursday, Friday Monday, Tuesday, Thursday, Friday8:30 am to 3:45 pm 8:30 am to 3:45 pm 8:00 am to 3:15 pm

[email protected] [email protected] [email protected]

623-866-6005 623-866-6007 623-866-6003Attendance Line Attendance Line Attendance Line

623-925-3100 623-866-6100 623-847-8531623-327-2708 Fax 623-000-0000 Fax 623-386-6049 Fax

Buckeye, Arizona 85326 Buckeye, Arizona 85326 Buckeye, Arizona 853264280 S. 246th Avenue 24155 W. Roeser Road 23800 W. Hadley Street

8:30 am to 3:45 pmWednesday

8:30 am to 1:45 pm 8:00 am to 1:15 pm 8:30 am to 1:45 pm

[email protected]

Monday, Tuesday, Thursday, Friday8:00 am to 3:15 pm

Wednesday

Attendance Line623-866-6001

[email protected]

Monday, Tuesday, Thursday, Friday


23601 W. Durango StreetBuckeye, Arizona 85326

623-925-3500623-386-4690 Fax

211 S. 7th StreetBuckeye, Arizona 85326

623-386-4487623-386-7901 Fax


Bales Elementary Buckeye Elementary Inca Elementary

25400 W. Maricopa RoadBuckeye, Arizona 85326

Jasinski Elementary Marionneaux Elementary Sundance Elementary

WestPark Elementary Preschool Buckeye Family Resource Center

[email protected]

Monday, Tuesday, Thursday, Friday8:30 am to 3:45 pm

Wednesday

623-847-8503623-327-0744 Fax

2700 S. 257th Drive 640 Centre Avenue 210 S. 6th Street, Bldg. 700Buckeye, Arizona 85326 Buckeye, Arizona 85326 Buckeye, Arizona 85326

623-435-3282 623-925-3921 623-925-3911623-386-3398 Fax 623-386-6219 Fax 623-386-3900 Fax

Attendance Line Attendance Line623-866-6004 623-925-3921 [email protected]

[email protected] [email protected]

8:00 am to 1:15 pm 7:00 am to 4:30 pm M-F 8:00 am to 5:00 pm

Monday, Tuesday, Thursday, Friday Monday - Friday 8:00 am to 3:15 pm 8:00 am to 5:00 pm

Wednesday Monday - Friday Summer Hours

25555 W. Durango St. * Buckeye, AZ 85326 * 623-925-3400 * www.besd33.org

INFORMATION SHEET PICKING UP YOUR CHILD Help us keep your child safe! Only those adults listed on your child(ren)’s CAN PICK UP list will be allowed to sign a child out of school. All adults will be required to provide photo ID before your child(ren) can be released. Please refrain from picking up your child(ren) within 15 minutes of their school’s regular dismissal time. VISITORS Please sign in at the front office of the school. A visitor badge will be provided. This helps us keep track of visitors to our campus and assists with the safety of our students. Please do not forget to bring a photo ID to verify your identity. PARENT PORTAL If you would like to keep track of your child(ren)'s grades and attendance, please register for a parent portal account. Your child(ren)'s school office can provide you with information regarding a parent portal account. To access the parent portal please go to https://buckeye.apscc.org/login_pxp.aspx. TRANSPORTATION Student Transportation Services are a privilege and not a right. Buckeye Elementary School District may withdraw bus privileges from any student who fails to follow the bus rules or directions given by the bus driver or other adult supervisor. Location, pick up time, drop off time and bus rules are available upon request. If you have any questions or concerns in regards to transportation, please contact our Transportation Coordinator at 623-925-3440. CHILD NUTRITION Buckeye Elementary School District (BESD) will be participating in the National School Lunch Program and the School Breakfast Program. As part of this program, all BESD schools will offer healthy meals every school day at NO COST to the students due to the implementation of Provision 2 for school year 2020/2021. Students will be able to participate in these meal programs without having to pay a fee but will be required to submit a household application for the base year. If you have questions for Child Nutrition, please contact our Child Nutrition Director at 623-925-3421. ARIZONA TAX CREDIT Arizona tax law (ARS 43-1089.01) allows taxpayers a credit for contributions made or fees paid to a public school for support of extracurricular activities. The credit is a dollar for dollar credit that is equal to the amount contributed or the amount of fees paid. However, the credit cannot exceed $200 for single taxpayers or heads of household. For married taxpayers who file a joint return, the credit cannot exceed $400. The tax credit can be claimed on personal income tax returns only. Contributions from businesses are welcome and are deductible, but cannot be used to claim a tax credit. Contributions made between January 1st and April 15th may be used as a tax credit on the current year or the previous year Arizona income tax return. Please consult your tax advisor. Now accepting tax credit donations online at https://az-buckeye.intouchreceipting.com. BUCKEYE FAMILY RESOURCE CENTER The Buckeye Family Resource Center is a partnership between First Things First and Buckeye Elementary School District. The center serves the Buckeye community and its surrounding areas. The focus is on early childhood literacy, nutrition, health, and child-centered activities. Programs, resources and referrals are provided for family members of all ages and the community. PRESCHOOL PROGRAM Our mission is to lay the foundation for our preschoolers to be passionate about learning, ready for Kindergarten, and set them up for success in receiving a world class education. Students are provided opportunities to problem solve, interact with peers, identify emotions and learn to self-regulate and become more independent thinkers. Students grow cognitively through developmentally appropriate practices based on the Early Learning Standards. Growth and development are measured through Teaching Strategies Gold. Students gain these skills through intentional play, vocabulary enrichment, consistent schedules, circle time, developmentally appropriate centers, and individualized lessons with their teacher and various staff. Through intentional play our students learn to follow instructions, practice active listening, sharing, taking turns, negotiating and cooperating skills. We make learning fun! If you have any questions about our preschool program, please contact the preschool at 623-925-3921. REGISTER TO VOTE In the United States, voter registration is the responsibility of the people, and only 70 percent of Americans who are eligible to vote have registered. Please support your child(ren)'s school by registering to vote. For more information on registering to vote, please go to http://www.dmv.org/az-arizona/voter-registration.php.

https://buckeye.apscc.org/login_pxp.aspx

https://az-buckeye.intouchreceipting.com/

http://www.dmv.org/az-arizona/voter-registration.php

179 School Days

S M T W T F S S M T W T F S1 2 3 4 1 2

5 6 7 8 9 10 11 3 4 5 6 7 8 9 93

12 13 14 15 16 17 18 10 11 12 13 14 15 16 98

19 20 21 22 23 24 25 17 18 19 20 21 22 23 102

26 27 28 29 30 31 24 25 26 27 28 29 30 107

31Jul 4 Independence Day (Holiday)

S M T W T F S Jul 29-31 Staff Development S M T W T F S1 1 2 3 4 5 6 112

3 2 3 4 5 6 7 8 Aug 3-4 Staff Development 7 8 9 10 11 12 13 117

8 9 10 11 12 13 14 15 Aug 3 Meet the Teacher Night (6:00pm-7:30pm) 14 15 16 17 18 19 20 121

13 16 17 18 19 20 21 22 Aug 5 First Day of School 21 22 23 24 25 26 27 126

18 23 24 25 26 27 28 29 2819 30 31

Sep 7 Labor Day (Holiday)

S M T W T F S S M T W T F S23 1 2 3 4 5 1 2 3 4 5 6 131

27 6 7 8 9 10 11 12 Oct 2 End of 1st QT 7 8 9 10 11 12 1332 13 14 15 16 17 18 19 Oct 5-9 Fall Break (No School) 14 15 16 17 18 19 20 136

37 20 21 22 23 24 25 26 Oct 14-15 Parent Teacher Conferences 21 22 23 24 25 26 27 141

40 27 28 29 30 28 29 30 31 144

Nov 11 Veteran's Day (Holiday)

Nov 25-27 Thanksgiving (Holiday)

S M T W T F S S M T W T F S42 1 2 3 Dec 18 End of 2nd QT 1 2 3 145

4 5 6 7 8 9 10 Dec 21-31 Winter Break (No School) 4 5 6 7 8 9 10 150

47 11 12 13 14 15 16 17 Dec 25 Christmas Day (Holiday) 11 12 13 14 15 16 17 155

52 18 19 20 21 22 23 24 18 19 20 21 22 23 24 160

57 25 26 27 28 29 30 31 Jan 1 New Year's Day (Holiday) 25 26 27 28 29 30 165

Jan 4 SCHOOL RESUMES

Jan 18 Martin Luther King Day (Holiday)

S M T W T F S S M T W T F S62 1 2 3 4 5 6 7 166 8 9 10 11 12 13 14 Feb 3-4 Parent Teacher Conferences 2 3 4 5 6 7 8 170

71 15 16 17 18 19 20 21 Feb 15 Presidents' Day (Holiday) 9 10 11 12 13 14 15 175

73 22 23 24 25 26 27 28 16 17 18 19 20 21 22 179

74 29 30 Mar 5 End of 3rd QT 23 24 25 26 27 28 29Mar 8-12 Spring Break (No School) 30 31

S M T W T F S Apr 2 Good Friday (Holiday) S M T W T F S77 1 2 3 4 5 1 2 3 4 582 6 7 8 9 10 11 12 May 20 Last Day of School (2 hour early out) 6 7 8 9 10 11 1287 13 14 15 16 17 18 19 May 31 Memorial Day (Holiday) 13 14 15 16 17 18 19

20 21 22 23 24 25 26 20 21 22 23 24 25 2627 28 29 30 31 27 28 29 30

No School Parent Teacher Conferences

Early Release First & Last Day of School

August 2020

December 2020

February 2021

September 2020

April 2021

May 2021November 2020

JANUARY

FEBRUARY

MARCH

APRIL

DECEMBER

SEPTEMBER

OCTOBER

NOVEMBER

June 2021

2020-2021 Parent Calendar

July 2020

October 2020

March 2021

January 2021

JULY

AUGUST

Buckeye, Sundance & WestPark Bales, Inca, Jasinski, & Marionneaux

Monday, Tuesday, Thursday, & Friday

8:00 am to 3:15 pm

MAY

Staff Development, No Students

School Holiday

Wednesday

8:00 am to 1:15 pm

Monday, Tuesday, Thursday, & Friday

8:30 am to 3:45 pm

Wednesday

8:30 am to 1:45 pm


McKinney-Vento Eligibility QuestionnaireStudent Surveys Consent FormMigrant Education ProgramPHLOTE Home Language Survey

Food Service Application

Enrollment Packet Checklist

Authorization for Release / Request for Student RecordsHealth Information FormStudent Services Questionnaire

Proof of Residency (A.R.S. §15-802 Section B) Immunization Record (A.R.S. §15-872 Section B)Original or Certified Copy of Birth Certificate (A.R.S. §15-828 Section A)Withdrawal Form from Pupil’s Previous School Attended in this State (A.R.S. §15-827 Section A)

Arizona Residency Documentation Form or Affidavit of Shared Residence

YOU MUST BRING THE FOLLOWING DOCUMENTS WITH YOU AT THE TIME OF REGISTRATION. THE REGISTRATION PROCESS CANNOT BE COMPLETED UNLESS WE HAVE ALL THE FOLLOWING DOCUMENTS:

Registration Form – Part 1Registration Form – Part 2

YOUR ENROLLMENT PACKET INCLUDES THE FOLLOWING FORMS TO BE COMPLETED AND RETURNED TO THE SCHOOL OFFICE:

SCHOOL OFFICE USE ONLY

Student Registration Form - PART 1

Entered into SIS by:Student Perm ID#:Start (Enter) Date: Date Entered in SIS: Grade: Teacher:

STUDENT INFORMATION – NAME AS IT APPEARS ON BIRTH CERTIFICATE OR LEGAL DOCUMENT Student’s Last Name Student’s First Name Grade Gender

M FSuffixStudent’s Middle Name

Date of Birth (MM/DD/YYYY) Age Birth Country

Zip

Birth StateBirth City

StateStudent’s Primary Home Address (REQUIRED) Subdivision City

City

Ethnicity (CHECK ONE) Hispanic/Latino NOT Hispanic/Latino

Race (Check ONE or MORE, regardless of ethnicity) Black or African American White Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander

PARENT/GUARDIAN INFORMATION – MUST BE LISTED ON BIRTH CERTIFICATE OR LEGAL CUSTODY DOCUMENTATION

Primary Phone Number (REQUIRED) Cell Home Work Secondary Phone Number Cell Home Work

State ZipStudent’s Mailing Address (if different from Home Address) Subdivision

1 Lives With Student: Yes No Relationship: (Check ONE) Mother Father Guardian Foster Parent Step-Mother Step-Father

CONTACT THIS

PERSON 1ST 2ND 3RD

Last Name, First Name (as it appears on Driver’s License)

Date of Birth (MM/DD/YYYY) Home Address, City, State, Zip Same as Student

Email Address

Birth Place

Alternate Phone Number Cell Home WorkPrimary Phone Number Cell Home Work Alternate Phone Number Cell Home Work

Active Military Yes No




CONTACT THIS

PERSON 1ST 2ND 3RD

Alternate Phone Number Cell Home Work Alternate Phone Number Cell Home Work

Email Address

Home Address, City, State, Zip Same as StudentBirth Place

Primary Phone Number Cell Home Work


Date of Birth (MM/DD/YYYY)



Email AddressCONTACT

THIS PERSON 1ST 2ND 3RD


Date of Birth (MM/DD/YYYY) Home Address, City, State, Zip Same as Student


EdFi ID #:

Birth Place

Primary Phone Number Cell Home Work Alternate Phone Number Cell Home Work Alternate Phone Number Cell Home Work

Enter Code:

Previously Enrolled in District? Yes No Campus:________________________________

Bus Walker Parent Pick Up

ELL SpEd/Speech Migrant 504 Gifted Homeless

CTDS:

070433School #:


Name of previous school attended

Bales Elementary Marionneaux Elementary

Buckeye Elementary Preschool

Inca Elementary Sundance Elementary

Jasinski Elementary WestPark Elementary

1

2

Parent/Guardian Signature: Date:

Has the student been identified for Gifted Services?

Yes No

Relationship: (Check ONE) Aunt Family Friend Grandparent Sibling Age 18+ Step-Mother Step-Father Uncle Case Worker Daycare Cousin Age 18+

STUDENT EMERGENCY CONTACTS: PERSONS OTHER THAN PARENT/GUARDIAN - NEED TO PROVIDE AT LEAST ONE

DISCIPLINE INFORMATION-SUSPENSION/EXPULSION

Has the student ever been retained? Yes No

If Yes, at what grade level? ___________

School Grade

Student’s Last Name Student’s First Name School Grade

Grade:

Grade:

Grade:

PARENT/GUARDIAN SIGNATUREI, the undersigned, do hereby authorize officials of Buckeye Elementary School District to contact the person(s) named on this form or updated forms and/or permission is granted to transport, render aid, treatment or care as deemed necessary in an emergency. In the event the parent and other person(s) named on either form cannot be contacted, the school officials are hereby authorized to take whatever action is necessary in their judgment. I will not hold the school district financially responsible for the emergency care and/or transportation of said child. I certify that I am a parent with legal control of the child. I understand that it is my responsibility to contact Buckeye Elementary School District if I wish to change any information on this form or to revoke my consent given herein.

Preschool

Has the student attended school in the USA within the past 3 years? Yes No

If Yes, which school/district? ______________________________________________If Yes, which school/district? ___________________________________________________

Has the student ever attended another school in Arizona? Yes No

Year:

Last Name, First Name (as it appears on Driver’s License) Primary Phone Number Cell Home Work

Primary Phone Number Cell Home Work Alternate Phone Number Cell Home WorkLast Name, First Name (as it appears on Driver’s License)

Has the student ever attended any of the Buckeye Elementary District Schools: Yes No If Yes, indicate which school, year and grade attended:

Has this student ever been suspended from School? Yes No If Yes, Date, Reason, School/District

STUDENT BACKGROUND INFORMATION

Student Registration Form - PART 2STUDENT INFORMATION – NAME AS IT APPEARS ON BIRTH CERTIFICATE OR LEGAL DOCUMENT Student’s Last Name Grade Gender

M F

Date of Birth (MM/DD/YYYY)Student’s First Name

Grade:

School Grade

Student’s Last Name

LIST SIBLINGS ATTENDING ANY SCHOOL WITHIN BUCKEYE ELEMENTARY SCHOOL DISTRICTStudent’s Last Name Student’s First Name

Student’s Last Name

Student’s First Name


GradeSchool

Grade:Year:

Alternate Phone Number Cell Home Work

HOW DID YOU HEAR ABOUT USPlease Choose One Facebook Family or Friend Instagram Mailer Movie Theater Twitter Website Word of Mouth Other

Relationship: (Check ONE) Aunt Family Friend Grandparent Sibling Age 18+ Step-Mother Step-Father Uncle Case Worker Daycare Cousin Age 18+

Has this student ever been expelled from School? Yes No If Yes, Date, Reason, School/District

If Yes, Date, Reason, School/DistrictHas either action ever been recommended for this student? Yes No

If my child is being sent home or must leave school and attempts to reach me have failed, I authorize the following persons to pick up my child. I understand that if the name of the person picking up my child does not appear on this list or the person does not have a photo ID, my child will not be released from school to that person.

Year:

Grade: Year:

Year: Grade:

Year:

Grade:

Year:

Year:



Bales Elementary School Marionneaux Elementary School

25555 W. Durango Street, Buckeye, AZ 85326 25555 W. Durango Street, Buckeye, AZ 85326

(623) 847-8503 / (623) 327-0744 (fax) (623) 866-6100 /

Email: [email protected] Email: [email protected]

Buckeye Elementary School Preschool


(623) 386-4487 / (623) 386-7901 (fax) (623) 925-3921 / (623) 386-6219 (fax)


Inca Elementary School Sundance Elementary School


(623) 925-3500 / (623) 386-4690 (fax) (623) 847-8531 / (623) 386-6049 (fax)


Jasinski Elementary School WestPark Elementary School


(623) 925-3100 / (623) 327-2708 (fax) (623) 435-3282 / (623) 386-3398 (fax)


All Academic Records Immunization/Health Records

Birth Certificate Last Report Card

Discipline Records MOWR Status (move on with reading)

English Language Scores/Records (ELL) Test Scores

Gifted Records Withdrawal Form

Date Sent: Requested By:



1st Request:

2nd Request:

3rd Request:

INFORMATION REQUESTED

PLEASE SEND SPECIAL EDUCATION RECORDS FOR ALL SCHOOLS TO:Buckeye Elementary School District

ATTN: Student Service25555 W. Durango Street, Buckeye, AZ 85326

Phone: (623) 925-3400 x3405 Fax: (602) 386-6063

Email: [email protected]

Fax Email Mail

Fax Email Mail

Fax Email Mail

PARENT/GUARDIAN SIGNATUREIn accordance with A.R.S.§ 15-828, I authorize the release of all records, to Buckeye Elementary School District, including birth certificate, academic (education), medical (health), psychological, specialeducation, social developement, and gifted information regarding the above pupil.

REQUESTING SCHOOL

Name of District

Address City State Zip

BELOW FOR OFFICE USE ONLY

PREVIOUS SCHOOL ATTENDED INFORMATION Name of previous school attended

Fax EmailPhone

Authorization for Release of and Request for Student RecordsSTUDENT INFORMATION - NAME AS IT APPEARS ON BIRTH CERTIFICATE OR LEGAL DOCUMENT Student’s Last Name Grade Gender

M F


Student’s Last Name Student’s First Name

Allergies (seasonal, environmental)

Allergies (food, insects, drugs, latex, etc.):

Arthritis

Asthma

Attention Deficit Disorder/Hyperactivity

Behavior Problems

Bladder or Bowel Problems

Bleeding Disorder

Cancer/Leukemia

Chest/Lung Disease

Chickenpox (indicate year):

Diabetes

Heart Condition

Migraines

Neurological Disorder

Seizures (Epilepsy)

Other:

Other:

Chronic Ear Infections

Hearing Aids

Known Hearing Loss (please provide documentation)

Myringotomy (tubes in ears)

Color Deficiency

Known Vision Loss Right Eye Left Eye Both Eyes

Wears Contacts

Wears Eyeglasses

Physician Name Phone Hospital

Surgeries/Hospitalizations:

Other Health Information:

PARENT/GUARDIAN SIGNATURE


I, the undersigned, do hereby authorize officials of Buckeye Elementary School District to contact the person(s) named on the student's emergency contact list in the event the parent cannot be contacted. In the event the parent/guardian or emergency contact person(s) cannot be reached, the school officials are hereby granted authorization to transport, render aid, treatment or care as deemed necessary in an emergency. I will not hold the school district financially responsible for the emergency care and/or transportation of said child. I certify that I am a parent with legal control of the child. I understand that it is my responsibility to contact Buckeye Elementary School District if I wish to change any information on this form or to revoke my consent given herein.

Health Information Form

HEARING HISTORY - PLEASE MARK ANY ITEMS THAT APPLY TO THE ABOVE STUDENT

VISION HISTORY - PLEASE MARK ANY ITEMS THAT APPLY TO THE ABOVE STUDENT

OTHER HEALTH INFORMATION

Grade GenderM F

STUDENT INFORMATION - NAME AS IT APPEARS ON BIRTH CERTIFICATE OR LEGAL DOCUMENT

MEDICAL HISTORY - PLEASE MARK ANY ITEMS THAT APPLY TO THE ABOVE STUDENT


Student’s Last Name Student’s First Name Date of Birth (MM/DD/YYYY)

Parent's Last Name Parent's First Name Parent's Phone

Diphenhydramine (Benadryl) for mild allergic reactions Yes No

Throat/Cough Lozenges for sore throat or cough Yes No

Tums or Rolaids for upset stomach Yes No

Acetaminophen (Tylenol) for minor pain or fever Yes No

Ibuprofen (Motrin) for mild pain or fever Yes No

PARENT SIGNATURE


Apellido del Estudiante Nombre del estudiante

Apellido del padre Nombre del padre Teléfono del padre

Diphenhydramine (Benadryl) para reacciones alérgicas leves Sí No

Pastillas para la tos o para el dolor de garganta Sí No

Tums o Rolaids para malestar estomacal Sí No

Acetaminofeno (Tylenol) para dolor leve o fiebre Sí No

Ibuprofeno (Motrin) para dolor leve o fiebre Sí No

FIRMA DE LOS PADRES

Firma del Padre / Tutor: Fecha:

INFORMACIÓN DEL ESTUDIANTE

Medication Authorization FormBuckeye Elementary School District has over the counter medication "Standing Orders". With your permission, we will be able to administer over the counter

medications to your child. We are asking all parents/guardians to sign a new authorization form for the administration of these medications. Medications will be

dispensed by the School Health Office or the Principal's Designee. Written permission is valid for the current school year. STUDENT INFORMATION

Grade Gender:M F

MEDICATIONS - PLEASE MARK MEDICATIONS THAT THE ABOVE STUDENT IS ALLOWED OR NOT ALLOWED TO RECEIVE AT SCHOOL*** Over the counter medications will only be administered between the hours of 11:00am to 2:30pm ***

If a parent/guardian or designated friend/relative cannot be reached, I hereby give authority to any hospital or medical professional to render immediate aid as might be required at the time for his/her health and safety. It is understood by me that the expense if this service will be accepted by me.

Formulario de autorización de medicamentosEl Distrito Escolar Primario de Buckeye tiene medicamentos de venta libre de "Ordenes permanentes". Con su permiso, podremos administrar medicamentos sin

receta a su hijo. Le pedimos a todos los padres / tutores que firmen un nuevo formulario de autorización para la administración de estos medicamentos. Los

medicamentos serán administrados por la Oficina de Salud Escolar o el Designado por el Director. El permiso por escrito es válido para el año escolar actual.

*** Los medicamentos sin receta sólo se administrarán entre las horas de 11:00 am a 2:30 pm ***

Si no se puede localizar a un padre / guardián o amigo / pariente designado, por la presente autorizo a cualquier hospital o profesional médico a prestar la ayuda inmediata que pudiera ser necesaria en el momento para su salud y seguridad. Se entiende por mí que el gasto por este servicio será aceptado por mí.

Fecha de nacimiento (MM/DD/AA) Grado Género:M F

MEDICAMENTOS-POR FAVOR MARQUE MEDICAMENTOS QUE EL ESTUDIANTE TIENE PERMITIDO O NO SE LE PERMITE RECIBIR EN LA ESCUELA

Autism Multiple Disabilities Orthopedic Impairment Traumatic Brain Injury

Developmental Delay Mild Intellectual Disability Severe Intellectual Disability Visual Impairement

Emotional Disability Moderate Intellectual Disability Specific Learning Disability 504 Plan:

Hearing Impaired Other Health Impairment Speech/Language Impairment Other:


Name of previous school attended Name of District

Student Services QuestionnaireSTUDENT INFORMATION – NAME AS IT APPEARS ON BIRTH CERTIFICATE OR LEGAL DOCUMENT Student’s Last Name Student’s First Name Date of Birth (MM/DD/YYYY) Gender

M FGrade

SPECIAL EDUCATION INFORMATION

Was your student receiving special education services at their previous school? Yes No

Was your student receiving 504 accommodations at their previous school? Yes No

Was your student receiving ELL services (English Language Learners) at their previous school? Yes No

If Yes to any of the above questions, please complete the below portion of this form and sign at the bottom

SELECT SPECIAL EDUCATION SERVICES RECEIVED OR 504 ACCOMMODATIONS RECEIVED:

If No to ALL above questions, please STOP and sign here Parent/Guardian Signature: Date:

PREVIOUS SCHOOL ATTENDED INFORMATION

Do you have a copy of the current IEP or 504 Plan? Yes No

Do you have a copy of the current Psychological Evaluation Report (MET)? Yes No

*** If you have copies of the current IEP and MET Report, please provide a copy to the school or Student Services located at the Buckeye Elementary Central Office ***

Address City State Zip

PARENT/GUARDIAN SIGNATUREI hereby certify that I am the child’s parent or legal guardian and that the information I have given above is true and correct to the best of my knowledge. I hereby authorize the release of special education records for the above child.

Phone Fax Email

STUDENT AND PARENT INFORMATIONStudent’s Primary Home Address City State Zip

Parent Name Primary Phone Number Cell Home Work

In a motel In a shelter With more than one family in a house or apartment In a place not designated for ordinary sleeping accommodations such as a car, park, or campsite

Parent/Guardian: Date:

TRANSPORTATION

Will your child need transportation if it is determined that they qualify for the McKinney-Vento Act? Yes No

State GradeSchool Name City Country School Year

3. Is the student under refugee status? Yes No

McKinney-Vento Eligibility QuestionnaireThis questionnaire is intended to address the McKinney-Vento Act 42 U.S.C. 11435

Student’s Last Name Student’s First Name Date of Birth (MM/DD/YYYY) Grade GenderM F

Name of School

1. Is your current address a temporary living arrangement? Yes No

2. Is this temporary living arrangement due to loss of housing or economic hardship? Yes No

The answers will determine the services that the student may be eligible to receive.

If yes, please indicate Country ________________________________________ Effective Date ____/____/_____

4. If born outside of the US, are the parents in the US Military? Yes No

Name of Parent(s)/Legal Guardian(s):

Physical Address City State Zip

If you answered YES to ANY of the above questions, please complete the remainder of the form.If you answered NO to ALL of the above questions, you may stop here.

Where is the student presently living? (Check One)

List all schools attended for the past three (3) years


The undersigned Parent/Guardian certifies that the information provided is true and accurate.

Primary Phone (include area code) Secondary Phone Secondary Phone

Critical appraisals about another person with whom the Political affiliations/opinions/beliefsstudent has a close relationship

Gun or ammunition ownership Biometric information about the student

Illegal/antisocial/ or self-incriminating behavior Quality of interpersonal relationships in the home

Income or other financial information Religious practices/affiliations/beliefs

Legally recognized privileged relationships, i.e., priest, Self-sufficiency during an emergency/disaster/or essentialattorney, doctor services interruption plans

Medical history/information Sexual behavior/attitudes

Mental health history/information Voting history


Student Surveys Consent FormSTUDENT INFORMATION

Grade


Student’s Last Name Student’s First Name

The Family Policy Compliance OfficeU.S. Department of Education

400 Maryland Avenue, SWWashington, DC 20202-4605

No, my student is not allowed to participate in student surveys as administered pursuant to A.R.S §15-117.PARENT CONSENT

Yes, my student is allowed to participate in student surveys as administered pursuant to A.R.S §15-117. Yes, my student is allowed to participate in the selected A.R.S §15-117 student surveys and no others. (A list of the types of survey areas are below, check the appropriate boxes)SURVEY AREAS PROTECTED BY A.R.S. §15.117CHECK THE FOLLOWING SURVEY AREAS IN WHICH YOUR STUDENT MAY PARTICIPATE:

The Buckeye Elementary School District Governing Board Policy JRR—Student Surveys, requires annual notification and written informed consent for the entire year from the parent of a pupil to participate in any survey administered pursuant to A.R.S. §15-117. A parent of a pupil may at any time revoke consent for the pupil to participate in any survey pursuant to subsection A of §15-117. All surveys conducted pursuant to subsection A of §15-117 shall be approved and authorized by the school district. A teacher or other school employee may not administer any survey pursuant to subsection A of §15-117 without written authorization from the school district.

A survey is only subject to §15-117 if the results are retained by the District for more than one year, it collects the student’s name or other identifiable information, one or more questions in the survey impacts one or more of the protected areas listed in the statute, and the survey does not fall under one of the exceptions. A parent may agree to allow a child to participate in some surveys, but not in others. Surveys collected under §15-117 cannot be released to third parties without “de-identifying” the results.

If a parent or eligible student believes that the District is violating the FERPA, that person has a right to file a complaint with the U.S. Department of Education at:

Last Name

Apellido

Relacion: (Marque UNO) Madra Padre Tutor Padre Adoptivo Madrastra Padrastro

Nombre

Direccion de Casa

Migrant Education ProgramSTUDENT INFORMATION Student’s Last Name Student’s First Name Student’s Middle Name School

If you answered YES to any of the above questions, your children may be eligible for services through the Buckeye Elementary School District Migrant Program. You will be contacted to set up an interview with staff from the Migrant Program.

Primary Phone Number Cell Home Work Alternate Phone Number Cell Home Work

NOMBRE DE LA PERSONA QUE COMPLETA ESTA FORMA

Migrante Educación ProgramaINFORMACION DEL ESTUDIANTE Apellido del Estudiante Primer Nombre del Estudiante Segundo Nombre del Estudiante Escuela

NAME OF PERSON COMPLETING THIS FORMRelationship: (Check ONE) Mother Father Guardian Foster Parent Step-Mother Step-Father

PLEASE ANSWER YES OR NO TO THE FOLLOWING QUESTIONSHave you worked in agriculture-related jobs (such as field work, fruit or vegetable packing companies, dairies, or ranches) in the last 3 years?

Have you left the school district with your family to go work in the fields, packing companies, dairies, or ranches?

First Name

Home Address City State Zip Code

Have you recently moved with your family from another city, state, Mexico or Canada to work in the fields, packing companies, dairies or ranches?

Si ha Mercado Si en una de las preguntas es possible que cualifican sus niño para servicios del Programa Migrante del Distrito Escolar Buckeye,el personal dosente del programa migrante les hablaran para hacer una entrevista con Ud.

Yes No

Yes No

Yes No

¿Ha trabajado usted en el campo de la agricultura, en la cosecha, empacadora de frutas y verduras, lecherìas, o ranchos en los últimos tres años? Sí No¿Se ha mudado usted recientamante con su familia de otra cuidad, estado, México o Canadá para trabajar en el campo, cosechas, empacadoras, lecherìas o Sí No¿Ha salido usted de este Distrito Escolar Buckeye con su familia para trabajar en el campo, cosechas, empacadoras, lecherìas o ranchos? Sí No

Codigo PostalCiudad Estado

POR FAVOR RESPONDA SI O NO A LAS SIGUIENTES PREGUNTAS

Numero de Telefono Primario Móvil Casa Trabajo Número de teléfono alternativo Móvil Casa Trabajo

Arizona Department of Education Office of English Language Acquisition Services

Office of English Language Acquisition Services 1535 West Jefferson Street • Phoenix, Arizona 85007 • (602) 542-0753 • www.azed.gov/oelas

Home Language Survey

The responses to this Home Language Survey (HLS) are used by the school to provide the most appropriate instructional programs and services for the student. The answers below will determine if a student will take the Arizona English Language Learner Assessment (AZELLA). Please respond to each of the three questions as accurately as possible. If you need to correct any of your responses, this must be done before the student takes the AZELLA Placement Test.

1. What language do people speak in the home most of the time?

_____________________________________________________________

2. What language does the student speak most of the time?

_____________________________________________________________

3. What language did the student first speak or understand?

_____________________________________________________________

Please provide a copy of the Home Language Survey to the EL Coordinator/Main Contact on site. In AzEDS, please enter all three HLS responses.

These HLS questions are in compliance with Arizona Administrative Code (R7-2-306(B)(1),(2)(a-c). (Revised 01-2020)

Student Name________________________________ District Student ID_______________

Date of Birth_________________________________ SSID__________________________

Parent/Guardian Signature______________________________ Date___________________

District or Charter____________________________________________________________

School_____________________________________________________________________

Buckeye Elementary School District #33

Arizona Department of Education Arizona Residency Documentation Form

Student__________________________________________ School _________________________ School District or Charter Holder __________________________________ Parent/Legal Guardian ______________________________________________________________ As the Parent/Legal Guardian of the Student, I attest* that I am a resident of the State of Arizona and submit in support of this attestation a copy of the following document that displays my name and residential address or physical description of the property where the student resides:

Valid Arizona driver’s license, Arizona identification card or motor vehicle registration Valid Arizona Address Confidentiality Program authorization card Real estate deed or mortgage documents Property tax bill Residential lease or rental agreement Water, electric, gas, cable, or phone bill Bank or credit card statement W-2 wage statement Payroll stub Certificate of tribal enrollment (506 Form) or other identification issued by a recognized

Indian tribe in Arizona Documentation from a state, tribal or federal government agency (Social Security

Administration, Veteran’s Administration, Arizona Department of Economic Security) Temporary on-base billeting facility (for military families)

I am currently unable to provide any of the foregoing documents. Therefore, I have provided an

original affidavit signed and notarized by an Arizona resident who attests that I have established residence in Arizona with the person signing the affidavit.

____________________________ ______________________ Signature of Parent/Legal Guardian Date

*For members of the armed services, the provision of verifiable documentation does not serve as a declaration of official residency for income tax or other legal purposes. Armed service members may utilize a temporary on- base billeting facility as the address for proof of residency.

I-6431 © 2009 Arizona School Boards Association IJNDB-E

BUCKEYE ELEMENTARY DISTRICT NO. 33 11/19/09

USE OF TECHNOLOGY RESOURCES IN INSTRUCTION

ELECTRONIC INFORMATION SERVICES USER AGREEMENT

Details of the user agreement shall be discussed with each potential user of the electronic information services (EIS). When the signed agreement is returned to the school, the user may be permitted use of EIS resources.

Terms and Conditions Acceptable use. Each user must:

• Use the EIS to support personal educational objectives consistent with the educational goals and objectives of the School District.

• Agree not to submit, publish, display, or retrieve any defamatory, inaccurate, abusive, obscene, profane, sexually oriented, threatening, racially offensive, or illegal material.

• Abide by all copyright and trademark laws and regulations. • Not reveal home addresses, personal phone numbers or personally identifiable data unless

authorized to do so by designated school authorities. • Understand that electronic mail or direct electronic communication is not private and may be read

and monitored by school employed persons. • Not use the network in any way that would disrupt the use of the network by others. • Not use the EIS for commercial purposes. • Follow the District's code of conduct. • Not attempt to harm, modify, add/or destroy software or hardware nor interfere with system

security. • Understand that inappropriate use may result in cancellation of permission to use the educational

information services (EIS) and appropriate disciplinary action up to and including expulsion for students.

In addition, acceptable use for District employees is extended to include requirements to: • Maintain supervision of students using the EIS. • Agree to directly log on and supervise the account activity when allowing others to use

District accounts. • Take responsibility for assigned personal and District accounts, including password

protection. • Take all responsible precautions, including password maintenance and file and directory

protection measures, to prevent the use of personal and District accounts and files by unauthorized persons.

Personal responsibility. I will report any misuse of the EIS to the administration or system administrator, as is appropriate. I understand that many services and products are available for a fee and acknowledge my personal responsibility for any expenses incurred without District authorization. Network etiquette. I am expected to abide by the generally acceptable rules of network etiquette. Therefore, I will:

• Be polite and use appropriate language. I will not send, or encourage others to send, abusive messages.

• Respect privacy. I will not reveal any home addresses or personal phone numbers or personally identifiable information.

I-6431 © 2009 Arizona School Boards Association IJNDB-E

BUCKEYE ELEMENTARY DISTRICT NO. 33 11/19/09

(Student or employee)

• Avoid disruptions. I will not use the network in any way that would disrupt use of the systems by others.

• Avoid disruptions. I will not use the network in any way that would disrupt use of the systems by others.

Be brief. Strive to use correct spelling and make messages easy to understand. Use short and descriptive titles for articles. Post only to known groups or persons.

Services. The School District specifically denies any responsibility for the accuracy of information. While the District will make an effort to ensure access to proper materials, the user has the ultimate responsibility for how the electronic information service (EIS) is used and bears the risk of reliance on the information obtained have read and agree to abide by the School District policy and regulations on appropriate use of the electronic information system, as incorporated herein by reference. I understand and will abide by the provisions and conditions indicated. I understand that any violations of the above terms and conditions may result in disciplinary action and the revocation of my use of information services. Name Signature Date School Grade (if a student)

Note that this agreement applies to both students and employees.

The user agreement of a student who is a minor must also have the signature of a parent or guardian who has read and will uphold this agreement.

Parent or Guardian Cosigner

As the parent or guardian of the above named student, I have read this agreement and understand it. I understand that it is impossible for the School District to restrict access to all controversial materials, and I will not hold the District responsible for materials acquired by use of the electronic information services (EIS). I also agree to report any misuse of the EIS to a School District administrator. (Misuse may come in many forms but can be viewed as any messages sent or received that indicate or suggest pornography, unethical or illegal solicitation, racism, sexism, inappropriate language, or other issues described in the agreement.)

I accept full responsibility for supervision if, and when, my child's use of the EIS is not in a school setting. I hereby give my permission to have my child use the electronic information services.

Parent/Guardian Name (print) Signature Date

Dear Parent/Guardian:

Children need healthy meals to learn. Buckeye Elementary School District offers healthy meals every school day at NO COST to the students, due to the school’s participation in the Provision 2 program of the National School Lunch/School Breakfast Programs.

While the meals are provided at no cost, the school must determine which students qualify for free meals or for reduced-price meals. This packet includes an application for free or reduced-price meal benefits, as well as a set of detailed instructions. Please fill the application and turn into the school administration. Below are some common questions and answers to help you with the application process.

1. WHO QUALIFIES FOR FREE MEALS?

a. All children in households receiving benefits from SNAP, FDPIR (Food Distribution Program on Indian Reservations) or TANF, can get free meals regardless of your income.

b. Foster children that are under the legal responsibility of a foster care agency or court are eligible for free meals.

c. Children participating in their school’s Head Start Program are eligible for free meals.

d. Children who meet the definition of homeless, runaway, or migrant are eligible for free meals.

e. Children can qualify for free or reduced-price meals if your household’s gross income is within the limits on the Federal Income Eligibility Guidelines. Your children may qualify for free or reduced-price meals if your household income falls at or below the limits on this chart.

Federal Eligibility Income Chart for School Year 2020-2021 Household Size Yearly Income Monthly Income Weekly Income

1 $23,606 $1,968 $454 2 $31,894 $2,658 $614 3 $40,182 $3,349 $773 4 $48,470 $4,040 $933 5 $56,758 $4,730 $1,092 6 $65,046 $5,421 $1,251 7 $73,334 $6,112 $1,411 8 $81,622 $6,802 $1,570

Each additional person: +$8,288 +$691 +$160

1. HOW DO I KNOW IF MY CHILDREN QUALIFY AS HOMELESS, MIGRANT, OR RUNAWAY? Do the members of your household lack a permanent address? Are you staying together in a shelter, hotel, or other temporary housing arrangement? Does your family relocate on a seasonal basis? Are any children living with you who have chosen to leave their prior family or household? If you believe children in your household meet these descriptions and haven’t been told your children will get free meals, please call Buckeye Elementary School District at 623.925.3400

2. DO I NEED TO FILL OUT AN APPLICATION FOR EACH CHILD? No. Use one Free and Reduced-Price School Meals Application for all students in your household. We cannot approve an application that is not complete, so be sure to fill out all required information. Return the completed application to: the Child Nutrition Department.

3. SHOULD I FILL OUT AN APPLICATION IF I RECEIVED A LETTER THIS SCHOOL YEAR SAYING MY CHILDREN QUALIFIED FOR FREE MEALS? No, but please read the letter you got carefully. If any children in your household were missing from your eligibility notification, contact 623.925.3400 immediately.

4. CAN I APPLY ONLINE? Absolutely!

Yes! You are encouraged to complete an online application instead of a paper application if you are able. The online application has the same requirements and will ask you for the same

information as the paper application. Visit EZMealApp.com to begin.

OR to learn more about the online application process please visit our website at BESD33.org

5. MY CHILD’S APPLICATION WAS APPROVED LAST YEAR. DO I NEED TO FILL OUT ANOTHER ONE? Yes. Your child’s application is only good for that school year and for the first few days of this school year through 09/09/2021. You must send in a new application unless the school told you that your child has already qualified for the new school year.

6. I GET WIC. CAN MY CHILD(REN) GET FREE MEALS? Children in households participating in WIC may qualify for free or reduced-price meals. Please fill out an application.

7. WILL THE INFORMATION I GIVE BE CHECKED? Yes. We may also ask you to send written proof of the household income you report.

8. IF I DON’T QUALIFY NOW, MAY I APPLY LATER? Yes, you may apply at any time during the school year. For example, children with a parent or guardian who becomes unemployed may become eligible for free and reduced-price meals if the household income drops below the income limit.

9. WHAT IF I DISAGREE WITH THE SCHOOL’S DECISION ABOUT MY APPLICATION? You should talk to school officials. You also may ask for a hearing by calling or writing to: Buckeye Elementary School District Child Nutrition Director Jason Woods 623.925.3421 [email protected]

10. MAY I APPLY IF SOMEONE IN MY HOUSEHOLD IS NOT A U.S. CITIZEN? Yes. You, your children, or other household members do not have to be U.S. citizens to qualify for free or reduced-price meals.

11. WHAT IF MY INCOME IS NOT ALWAYS THE SAME? List the amount that you normally receive. For example, if you normally make $1000 each month, but you missed some work last month and only made $900, put down that you made $1000 per month. If you normally get overtime, include it, but do not include it if you only work overtime sometimes. If you have lost a job or had your hours or wages reduced, use your current income.

12. WHAT IF SOME HOUSEHOLD MEMBERS HAVE NO INCOME TO REPORT? Household members may not receive some types of income we ask you to report on the application, or may not receive income at all. Whenever this happens, please write a 0 in the field. However, if any income fields are left empty or blank, those will also be counted as zeroes. Please be careful when leaving income fields blank, as we will assume you meant to do so.

13. WE ARE IN THE MILITARY. DO WE REPORT OUR INCOME DIFFERENTLY? Your basic pay and cash bonuses must be reported as income. If you get any cash value allowances for off-base housing, food, or clothing, it must also be included as income. However, if your housing is part of

the Military Housing Privatization Initiative, do not include your housing allowance as income. Any additional combat pay resulting from deployment is also excluded from income.

14. WHAT IF THERE ISN’T ENOUGH SPACE ON THE APPLICATION FOR MY FAMILY? List any additional household members on a separate piece of paper, and attach it to your application. Contact the Child Nutrition Department at 623.925.3400 to receive a second application.

15. MY FAMILY NEEDS MORE HELP. ARE THERE OTHER PROGRAMS WE MIGHT QYALIFY FOR? To find out how to apply for SNAP or other assistance benefits, contact your local assistance office or call 1-800-352-8401.

If you have other questions or need help, call the Child Nutrition Department at 623.925.3400.

Sincerely,

Jason Woods Child Nutrition Director

The Richard B. Russell National School Lunch Act requires the information requested in order to verify your children’s eligibility for free or reduced-price meals. If you do not provide the information or provide incomplete information, your children may no longer receive free or reduced-price meals. In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected].

This institution is an equal opportunity provider.

http://www.ascr.usda.gov/complaint_filing_cust.html

mailto:[email protected]

Please use these instructions to help you fill out the application for free or reduced-price school meals. You only need to submit one application per household, even if your children attend more than one school in Buckeye Elementary School District. The application must be filled out completely to certify your children for free or reduced-price school meals.

Each step of the instructions is the same as the steps on the application. If at any time you are not sure what to do next, please contact the Child Nutrition Department at 623.925.3400

Please use a pen (not a pencil) when filling out the application and do your best to print clearly. STEP 1- NAMES OF ALL CHILDREN IN THE HOUSEHOLD

List all household members who are infants, children, and students up to and including grade 12. This should include all children who live in your household. They do not have to be related to you to be part of your household.

List the first name, middle initial, and last name of each child. List one name per line and write one letter in each box. Stop if you run out of space. If you need additional lines, attach a second piece of paper with all required information for additional children.

If the children attend school, please list the name of the school.

If you believe the children are foster, homeless, migrant, or runaway, be sure to mark the box next to the child’s name under foster or homeless, migrant, runaway.

Once all children have been listed, go to STEP 2.

STEP 2- SNAP, TANF, OR FDPIR PARTICIPATION

Do any household members (including the adults) currently participate in one or more of the following assistance programs: SNAP, TANF, or FDPIR?

In the gray bar, circle either yes or no.

If Yes- List the case number in the large box labeled Case Number and go directly to STEP 4.

If No- Leave this section blank and go to STEP 3.

STEP 3- HOUSEHOLD INCOME INFORMATION

A. Child Income- Report all income earned by children in the household. Refer to the chart below titled “Sources of Income for Children” and report the combined gross income for all children listed in STEP 1 in the box marked “Total Child Income.”

Child Income is money received from outside your household that is paid directly to your children. Many households do not have any child income. Use the chart below to determine if your household has child income to report. If children do not receive income, enter ‘0’ or leave these boxes empty. If you leave this part blank, it will mean

that you have no income to report for any children in the household.

Only count foster children’s income if you are applying for them together with the rest of

your household. It is optional for the household to list foster children living with them as part of the household.

Sources of Income for Children Type of Income Examples Earnings from work A child has a job where they earn a salary or wages. Social Security

• Disability payments

• Survivor Benefits

A child is blind or disabled and receives Social Security benefits. A parent is disabled, retired, or deceased and their child receives social security benefits.

Income from persons outside the household

A friend or extended family member regularly gives a child spending money.

Income from any other source

A child receives income from a private pension fund, annuity or trust.

B. Adult Household Members and Income- Print the name of each household member

in the boxes marked “Names of Adult Household Members (First and Last).” Do not list any household members you listed in STEP1. List one name per line and write both first and last name in each box. If you need additional lines, attach a second piece of paper with all required information for additional household members.

Report gross income (amount before taxes and deductions) for each adult on the same line where the name is listed. Then, fill in the circle to indicate if the earnings are received Weekly, Bi-Weekly (every other week), 2x month (2 payments per month), or Monthly. The chart below gives examples of the different types of income for adults. If someone does not receive income, enter ‘0’ or leave these boxes empty.

Sources of Income for Adults Earnings from Work Public Assistance/

Alimony/Child Support Pensions/Retirement/All

Other Income Salary, wages, cash

bonuses Unemployment

benefits Social Security (including

railroad retirement and black lung benefits)

Net income from self-employment (farm or business)

For military families: Basic pay and cash

bonuses (do not

include combat pay,

FSSA, or privatized

housing allowances)

Allowances for off-base housing, food and clothing

Workers Compensation

Supplemental Security Income (SSI)

Cash Assistance from State or local government

Alimony payments Child support

payments Veteran’s benefits Strike benefits

Private Pensions or disability

Income from trusts or estates

Annuities Investment Income Earned Interest Rental Income Regular cash payments

from outside household

The back of this application provides the same Sources of Income charts.

C. Total number of household members and SSN. Report the total number of people in your household (all adults and children) in the one box. Report the last 4 digits of the Social Security Number (SSN) for the primary wage earner or other adult in the household. You are eligible to apply for benefits even if you do not have a Social Security Number. Simply leave the space blank and check the box labeled “Check if no SSN.”

STEP 4- Contact information and adult signature

All applications must be signed by an adult household member. By signing the application, that household member is promising that all information has been truthfully and completely reported.

Please sign, date and print your name.

Provide your contact information including your address if this information is available. If you have no permanent address, this does not make your children ineligible for free or reduced-price school meals. Sharing a phone number, email address, or both is optional but providing it helps us reach you quickly if we need to contact you.

Once the form is completed, it should be mailed, or delivered to your child’s school or the

District Central office at 25555 West Durango Road Buckeye, Arizona 85326

OPTIONAL INFORMATION

The back of this application provides a section for you to share information about your children’s

race and ethnicity. This field is optional and does not affect your children’s eligibility for free or

reduced-price school meals.

This section also includes important information about privacy and civil rights. Please read these statements before submitting the application.

The Richard B. Russell National School Lunch Act requires the information requested in order to verify your children’s eligibility for free or reduced-price meals. If you do not provide the information or provide incomplete information, your children may no longer receive free or reduced-price meals.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.






How often? Weekly Bi-Weekly 2x Month Monthly

Che

ck a

ll th

at a

pply

$

$

$

$

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Are you unsure what income to include here? Flip to the back of this application and review the charts titled “Sources of Income” for more information. The “Sources of Income for Children” chart will help you with the Child Income Section. The “Sources of Income for Adults” chart will help you with the Adult Household Members Income Section.

2020-2021 Application for Free and Reduced Price School Meals Complete one application per household. Please use a pen (not a pencil).

STEP 1 List ALL infants, children, and students up to and including grade 12 in your household (if more spaces are required for additional names, attach another sheet of paper)

Definition of Household Member: “Anyone who is

living with you and shares income and expenses, even if not related.”

Children in Foster care and children who meet the definition of Homeless, Migrant or Runaway are eligible for free meals.

Child’s First Name MI Child’s Last Name Foster Child

Homeless, Migrant, Runaway

STEP 2 Do any Household Members (including you) currently participate in one or more of the following assistance programs: SNAP, TANF, or FDPIR? Circle one: Yes / No

If you answered NO > Complete STEP 3. If you answered YES > Write a case number here then go to STEP 4 (Do not complete STEP 3) Case Number: Write only one case number in this space.

STEP 3 Report Income for ALL Household Members (Skip this step if you answered ‘Yes’ to STEP 2)

A. Child Income Sometimes children in the household earn income. Please include the TOTAL GROSS income earned by all Children Household Members listed in STEP 1 here.

Child GROSS income

$ B. All Adult Household Members (including yourself) List only the Adult Household Members (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report total GROSS income (amount before taxes and deductions) for each source in whole dollars only. If they do not receive income from any source, write ‘0’. If you enter ‘0’ or leave any fields blank, you are certifying (promising) that there is no income to report.

How often? Public Assistance/ Child Support/Alimony

How often? Pensions/Retirement/ All Other Income

How often? Name of Adult Household Members (First and Last)

$ $

$ $

$ $

$ $

C. Total Household Members (Children and Adults) X X X X X Check if no SSN

STEP 4

“I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of Federal funds, and that school officials may verify (check) the information. I am aware that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted under applicable State and Federal laws.”

Street Address (if available) Apt # City State Zip

Daytime Phone and Email (optional) Printed name of adult completing the form

Signature of adult completing the form Today’s date

Contact information and adult signature Mail Completed Form to: INSERT SCHOOL/DISTRICT MAILING ADDRESS

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Weekly Bi-Weekly 2x Month Monthly Weekly Bi-Weekly 2x Month Monthly

School Name

Weekly Bi-Weekly 2x Month Monthly GROSS Earnings from Work

OFFICE USE ONLY

Eligibility: Free___ Reduced___ Denied___ Determining Official’s Signature: ____________________________ Date: ____________________________

❑Case # Application ❑Foster Application ❑Directly Certified: Date of Disregard: _____________________ ❑Income Application Household Size: _______ Total Income: __________ Per: ❑Week ❑Bi-Weekly (Every 2 Weeks) ❑2x Month ❑Monthly ❑Annual

❑ Selected For Verification: Confirming Official’s Signature: _________________________ Date: ______________ Follow-Up Official’s Signature: ______________________________ Date: _______________

❑Error Prone

Last Four Digits of Social Security Number (SSN) of Primary Wage Earner or Other Adult Household Member

Sources of Income for Children

Type of Income Examples

Earnings from work A child has a job where they earn a salary or wages.

Social Security -Disability payments -Survivor Benefits

A child is blind or disabled and receives Social Security benefits. A parent is disabled, retired, or deceased and their child receives social security benefits.

Income from persons outside the household

A friend or extended family member regularly gives a child spending money.

Income from any other source

A child receives income from a private pension fund, annuity or trust.

Sources of Income for Adults

Earnings from Work Public Assistance/ Alimony/Child Support Pensions/Retirement/All Other Income

- Salary, wages, cash bonuses - Net income from self-employment (farm or business) If you are in the U.S. Military: - Basic pay and cash bonuses (do not include combat pay, FSSA, or privatized housing allowances) -Allowances for off-base housing, food and clothing

- Unemployment benefits - Workers Compensation - Supplemental Security Income (SSI) - Cash Assistance from State or local government

- Alimony payments - Child support payments - Veteran’s benefits - Strike benefits

- Social Security (including railroad retirement and black lung benefits)

- Private Pensions or disability - Regular income from trusts or estates - Annuities - Investment Income - Earned Interest - Rental Income - Regular cash payments from outside household




INSTRUCTIONS Sources of Income

We are required to ask for information about your children’s race and ethnicity. This information is important and helps to make sure we are fully serving our community. Responding to this section is optional and does not affect your children’s eligibility for free or reduced price meals.

Ethnicity (check one):

Race (check one or more):

Hispanic or Latino Not Hispanic or Latino

American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

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The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the last four digits of the social security number of the adult household member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules. In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Children's Racial and Ethnic Identities OPTIONAL



Documents

Bales Elementary Buckeye Elementary Inca Elementary · Buckeye Elementary School District (BESD) will be participating in the National School Lunch Program and the School Breakfast