Elementary School Enrollment Check List Elementary...Revised 1/6/17 ACAA Enrollment 2017-2018 Elementary School Enrollment Check List The following items must be turned in before your

Revised 1/6/17 ACAA Enrollment 2017-2018

Elementary School Enrollment Check List

The following items must be turned in before your child can be enrolled. Once the

registrar verifies completion of the enrollment form and validates all documents, your

child will be registered and classes assigned. If you have any questions or need any

assistance in obtaining documents please call Allison (Registrar) at 623-878-0986.

1. ACAA Enrollment Packet

2. Withdrawal form from previous school

3. Original birth certificate (copies not accepted)

4. Immunization records

5. Elementary Final Report Card (K-4)

6. All special education records (if applicable)

7. Legal guardian or custody papers (if applicable)

8. Proof of Arizona Residency

9. Attendance Record

10. Discipline Record

16454 N 28th Ave, Phoenix, Arizona 85053

Ph: (623)878-0986 Fax: (623)776-7956 http://azconservatory.org


Arizona Conservatory for Arts & Academics 16454 N 28th Ave Phoenix, AZ 85053 623-878-0986 Fax 623-776-7956

Student Enrollment

Form 2017-2018

School Use Only:

SAIS Number:

Date of Entry: Date Entered into PS: School Representative Signature

STUDENT INFORMATION Student's Legal Name:

Has Student Used Any Other Name? Today's Date:

Home Address:

City: State: Zip Code:

Mailing Address (if Different from home address)

City: State: Zip Code:

Circle One: Male Female

Birthplace:

Birth Date: Home Phone: Ethnicity:

Who does student live with? Grade this Year:

Last Grade Completed:

Last School Attended: Address & Phone Number of School:

What is the primary language used in the home regardless of the language spoken by the student?

What is the language most often spoken by the student?

What is the language that the student first acquired?

Are you on Probation? Name and Number of Probation Officer:

Did Student Receive Special Education Services at Previous School? [ ] YES [ ] NO If Yes, Date of Last I.E.P

Has student Been Expelled or Suspended from Any School? [ ] YES [ ] NO If Yes, Date & School:

Does your student have a current 504? [ ] YES [ ] NO How did you hear about ACAA?:

FAMILY HISTORY

Parent/Legal Guardian (Last, First, Middle):

Circle One: Mother/Father/Other

Home Phone:

Cell Phone: Work Phone:

Occupation:

Place of Employment:

Parent/Legal Guardian (Last, First, Middle):

Circle One: Mother/Father/Other

Home Phone:

Cell Phone:

Work Phone: Occupation:

Place of Employment:

Email Address:

Name and Age of Other Sibling Attending ACAA:

Transportation Requested: ( Y ) ( N ) If yes, list major crossroads:

SIGNATURE OF PARENT OR GUARDIAN: Date: ACAA REPRESENTATIVE & DATE:


Emergency contacts other than the two primary contacts on the first page:

_______________________________________________________ _______________________________________________________ EMERGENCY CONTACT #3 relationship to student EMERGENCY CONTACT #5 relationship to student _______________________________________________________ _______________________________________________________ Phone Numbers (home, cell, work, etc?) Phone Numbers (home, cell, work, etc?) ______________________________________________________ _______________________________________________________ EMERGENCY CONTACT #4 relationship to student EMERGENCY CONTACT #6 relationship to student _______________________________________________________ _______________________________________________________ Phone Numbers (home, cell, work, etc?) Phone Numbers (home, cell, work, etc?)

Student Health Information

Is there any special medical, educational, parent custody or other considerations the school should be aware of?

Has the student had any of the following? (Please check all that apply)

Epilepsy/Seizures ___ Auditory Processing Problem ___ Hearing Impairment ___ Visual Problem ___ Speech Problems ___ Allergies ___ Kidney Disease ___ Wears Glasses ___ Head Injury ___ Diabetes ___ Heart Disease ___ Asthma ___ Other ___ Please provide explanation of treatment for any of the checked items above:

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Has your child ever had Chicken Pox? __ YES __ NO

Is the student under treatment for any physical/mental disorder? __ YES __ NO If yes, please explain: ________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Allergies to Medicines__________________________________

*****All medications MUST be checked in and kept at the front office. The students may not carry them on their person. We DO NOT have a nurse on staff and we do not supply any type of medication (Tylenol, benadryl, etc). Parents can drop off medications at the front office and we will keep the medication, permission to dispense on file and document usage.

***Please read and initial in the space provided:

_____ In keeping with Arizona State Law, Arizona Conservatory Must receive a copy of the birth certificate and immunization records of the STUDENT(s). If the student has not been identified as homeless, the student will be withdrawn from the school should the birth certificate not be received within 30 days of enrollment.

*No Nurse on site – All Emergencies will be called in to 911 at parent's expense.


Temporary Placement for Special Education Services

Students Name:____________________ -Has the student ever qualified or been found eligible to receive special education services? YES_____ NO_____ If yes: Date_________ Last school where service was provided___________________Fax Number__________ -Is the student currently eligible to receive special education services? YES_____ NO_____ If yes: Date_________ Last school where service was provided___________________Fax Number__________ -Does the student have a current 504 Plan, including current medical documentation? YES_____ NO_____ If yes, please specify:__________________________________________________________ -Has the student ever received any of the following services: Resource: Speech/Language Therapy:

For Reading Previously_______ Currently______

Previously_______ Currently______ Physical Therapy:

For Writing Previously_______ Currently______

Previously_______ Currently______ Occupational Therapy:

For Math Previously_______ Currently______

Previously_______ Currently______ Self-contained Classroom:

Counseling: Previously_______ Currently______

Previously_______ Currently______

Initial

___I hereby give permission for my child to receive special education support services at ACAA. These services will be

provided while psychological and other special education records are received from my child’s previous school(s).

___I, DO NOT, give permission for my child to receive special education support services. I understand that services

will not be provided while psychological and other special education records are received from my child’s previous

school(s).

_______________________________________ __________

Parent/ Legal Guardian Signature Date

Child Find Policy

Arizona Conservatory for Arts & Academics (ACAA) will identify, locate, and evaluate all children with disabilities who are in need of special education and related services including, but not limited to, children who are: Homeless; Highly mobile, including migrant children; Wards of the state; and, Attending private schools or who are homeschooled.

ACAA will require all school-based staff members to review the written procedures related to child identification and referral on an annual basis, and maintain documentation of the staff review. [A.A.C. R7-2-401.D]. Identification screening for possible disabilities shall be completed within forty-five (45) calendar days after on any student enrolling without appropriate records or screening, evaluation, and progress in school; or parent notification of developmental or educational concerns.


Race and Ethnicity Identification Form

School: Arizona Conservatory for Arts & Academics Elementary Student Name: _____________________________ Date of Birth: ________________________ To Parents/Guardians: Complete and return this form as part of your student’s enrollment in ACAA. Please complete Parts 1 and

2 by marking the circle beside your answers. Part 1: Ethnicity Designation Directions: Read the definition below and completely darken the circle that indicates this student’s heritage. Is this student Hispanic or Latino? (Select one answer.) Persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race, are considered Hispanic or Latino.

◯ Yes ◯ No

Part 2: Race Designation Directions: Read the descriptions below and marking the circle or circles that indicate this student’s race. You must select at least one race, regardless of ethnicity designation. More than one response can be selected. Indicate this student’s race. (Select all that apply.)

◯ American Indian or Alaskan Native: A person having origins in any of the original peoples of North or South

America (including Central America), and who maintains a tribal affiliation or community attachment.

◯ Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian

subcontinent including Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

◯ Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii,

Guam, Samoa, or other Pacific Islands.

◯ Black or African American: A person having origins in any of the black racial groups of Africa.

◯ White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

I verify the information on this form is accurate. I refuse to re-identify the race and ethnicity of this student. _______________________________ ___/___/___ _________________________________ ___/___/___ Signature, Parent/Guardian Date Signature, Parent/Guardian Date

FOR SCHOOL USE ONLY I am the observer who completed this form due to parent/guardian refusal to re-identify.

____________________________________ ___/___/___

Signature, Observer Date


K-1

Date: ________ Contact Phone#:____________________ Circle entering grade: K 1

Name: __________________________________________ Gender: M F

Last First

Your child will automatically be placed in all of the following classes:

Mathematics Music

Reading Art

Writing Physical Education

Social Studies

Science

Careers & Life Explorations

Intervention

Computerized selection will be made; order will not necessarily coincide with order shown.

*An Arts fee is required and must be paid prior to the beginning of the school year to guarantee enrollment in the appropriate

arts class. If your child qualifies for free or reduced lunch, the fee is discounted.

If you currently have an IEP or 504 Plan, check the appropriate space: _____ IEP _____ 504

I understand that my child will be scheduled into the above classes unless they are filled, canceled, or any

prerequisites has not been met.

_____________________________________________ ___________________________

Parent/Guardian's Signature Student Signature

Arizona Conservatory for

Arts & Academics

Registration 2017-2018


2-3

Date:________ Contact Phone#:____________________ Circle entering grade: 2 3

Name: __________________________________________ Gender: M F

Last First


Mathematics

Reading

Writing

Social Studies

Science


Intervention

Advisory


*An Arts fee is required and must be paid prior to the beginning of the school year to guarantee enrollment in the appropriate arts class.

If your child qualifies for free or reduced lunch, the fee is discounted.

Electives: Rank choice 1-4, with one being your first choice. The number of elective classes per semester varies and depends upon the

student's specific academic course needs. Not all classes may be offered. Students that are below grade level in either Math, and/or

Reading will be placed in a Title I course as an elective.

_____ Ballet _____ Music ______ Physical Education _____ Visual Art

If you currently have an IEP or 504 Plan, check the appropriate space: _____ IEP _____504

I understand that my child will be scheduled into the above classes unless they are filled, canceled, or any


__________________________________________ ___________________________________



Arts & Academics



4-5

Date:________ Contact Phone#:____________________ Circle entering grade: 4 5

Name: __________________________________________ Gender: M F

Last First


Mathematics

Social Studies

Science

English


Intervention

Advisory


*An Arts fee is required and must be paid prior to the beginning of the school year to guarantee enrollment in the appropriate

arts class. If your child qualifies for free or reduced lunch, the fee is discounted.

Electives: Rank choice 1-4, with one being your first choice. The number of elective classes per semester varies and depends upon

the student's specific academic course needs. Not all classes may be offered. Students that have not met the AzMerit requirements

or are below grade level in either Math, and/or Reading will be placed in a Title I course as an elective.

_____ Band _____ Ballet ____ Music _____ Physical Education

_____ Orchestra _____ Visual Arts

If you are currently have an IEP or 504 Plan, check the appropriate space: _____ IEP _____ 504

I understand that I will be scheduled into the above classes unless they are filled, canceled, or any


__________________________________________ ___________________________________



Arts & Academics



Arizona Conservatory for Arts and Academics 16454 28th Ave, Phoenix, Arizona 85053

Ph: (623)878-0986 Fax: (623)776-7956 http://arizonaconservatory.org

Attention: Alice Armenta or Allison Kennedy

AUTHORIZATION FOR RELEASE AND REQUEST OF STUDENT RECORDS

STUDENT'S LEGAL NAME (Last, First, Middle)

DATE of BIRTH

PREVIOUS SCHOOL ATTENDED FAX NUMBER

GRADE ENTERING

ADDRESS OF PREVIOUS SCHOOL

CITY

STATE

ZIP CODE

Please send the following records:

(ARS 15-827 &15-828 Sect F states that official records cannot be withheld due to owed fees)

OFFICIAL WITHDRAWAL FORM ATTENDANCE O.T. & P.T./ PSYCH RECORDS

CUM FILE BIRTH CERTIFICATE IEP OR 504 PLAN

LEGAL DOCUMENTS IMMUNIZATION METS

OFFICIAL TRANSCRIPTS HEALTH RECORDS SPEECH/ LANGUAGE/ AUDIO

ALL STATE TESTING RESULTS HEAR/VISION ALL SPECIAL EDUCATION RECORDS

DISCIPLINE RECORD Arizona English Language Learner Assessment

WITHDRAW GRADES

PLEASE PROVIDE STUDENT'S SAIS #:

PREVIOUS SCHOOL IF LESS THAN TWO YEARS:

ADDRESS: CITY STATE ZIP CODE

PHONE: FAX:

SIGNATURE OF PARENT/GUARDIAN

DATE:

ACAA REPRESENTATIVE DATE

Date of 1st Request: Date of 2nd Request:

In accordance with the Family Education Act of 1974 and Arizona State Law, PARENT PERMISSION IS NO LONGER REQUIRED when records are requested by authorized school personnel.

ARS Section 15-828 (F) requires to forward a certified copy of the student's records, including state.


Contract of Expectations

ACAA is dedicated to providing a safe and supportive environment where respect and responsibility are expected and fostered. Parents and the school work in harmony to ensure students are making appropriate progress. To that end, we ask for your support in enforcing the following expectations: Expectation #1: Students will respect and obey the law.

Students involved in any illegal activity occurring on or off school property will be met with zero tolerance resulting in immediate suspension or expulsion. These activities include, but are not limited to, possession or use of tobacco or alcohol; activities related in any way to the purchase, use, or possession of drugs; gang related activities; possession of weapons; or abuse. Theft, vandalism, or other mistreatments of property belonging to others (including the school) will result in consequences, which may range from a detention to expulsion, and may include restitution of stolen or damaged items or police involvement.

Expectation #2: Students will respect the ideas, beliefs, cultures, and individual differences of others.

Students engaging in verbal or written abuse, intimidation, harassment, discrimination, disrespect of authority, fighting, profanity, obscene behavior, extortion, gang-related activities, or other such behaviors will receive consequences ranging from an informal conference to expulsion based on attitude, severity, and prior history.

Expectation #3: Students will respect the privilege of acquiring the best education possible.

Plagiarism, lying, cheating, dress code violation (when on campus and/or participating with others in school activities), public displays of affection (when on campus and/or participating with others in school activities), or any form of academic misconduct will result in consequences ranging from an informal conference to expulsion based on attitude, severity and prior history.

Expectation #4: Students will be responsible citizens of the Internet. Students and parents/guardians must agree to abide by the following as users and citizens of the Internet "netizens":

1. I recognize and accept the responsibility for my actions and conduct on the Internet. 2. I will not participate in any type of inappropriate behavior while online. Inappropriate behavior includes,

but is not limited to, accessing, viewing and/or distributing vulgar or demeaning language, images and/or audio, hacking, damaging and/or altering software, data and/or hardware so as to harm and/or inconvenience others.

3. I will be courteous and respectful of property (including, but not limited to, data, programs and/or information) and people on the Internet.

4. ACAA/Sequoia Schools computer and Internet resources will not be used for commercial purposes without prior written consent of Sequoia Schools Governing Board.

5. Use of the Internet and computers of ACAA/ Schools is a privilege, not a right. Abuse and/or misuse of that privilege may result in loss of that privilege and/or other academic and/or disciplinary action.

6. Parents and students recognize that ACAA is not able or responsible for filtering incoming Internet e-mail, the content of chat groups, or news groups. It is imperative that parents monitor computer use carefully.

**Please initial below that you have read and understood the Internet Usage Agreement (Expectation # 4 & # 5) above: ______ Student Initials _____ Parent Initials


Expectation #5: Parents/Guardians will monitor attendance.

Educational hours are tracked in the categories set forth in the Arizona State Standards. Parents must contact the school by 8:00 am every day the student is absent. Ten days of consecutive unexcused absences without prior authorization by the school will result in the withdrawal of the student. Please see the Student Handbook for further details/requirements for absences.

Expectation #6: Parents/Guardians will be responsible for student transportation. Parents must provide transportation to and from the campus. There is limited bus transportation available. Please contact the school to receive further details.

High School Students - Please read this notice carefully:

ACAA does not discriminate in its enrollment policy. Students applying for enrollment may be tested to determine appropriate placement regardless of age, prior grade level or experience. If it is determined that a student is not ready for high school courses, it will be necessary to give them appropriate curriculum for their level.

I have read this Contract of Expectations and agree to be subject to its contents while participating in any school activities. I further recognize that I will be held responsible for my actions according to this contract and the consequences herein. By signing my name on the line below I recognize it is legally binding. I also certify that I have custodial rights for the student I am enrolling and as such, the responsibility for their education.

______________________________________________________ Parent/Guardian Signature Date ______________________________________________________ Student Signature Date

SCHOOL PHOTO/VIDEO PERMISSION _______I HEREBY GRANT PERMISSION FOR MY CHILD TO BE PHOTOGRAPHED OR

VIDEOTAPED IN ANY SCHOOL RELATED ARTICLE, BROCHURE, VIDEO PRODUCTION

OR OTHER PUBLICATION.

_______I DO NOT GRANT PERMISSION FOR MY CHILD TO BE PHOTOGRAPHED OR

VIDEOTAPED IN ANY SCHOOL RELATED ATICLE, BROCHURE, VIDEO PRODUCTION

OR OTHER PUBLICATION.

_____________________________________________ ___________ Signature of Parent/Guardian Date


Parent Volunteer Opportunities Dear Parents/Guardians:

It is imperative to the success of your child and the school for our parents to actively

participate in their child’s academic and arts education. Your time is needed in all school related

areas. Please choose from the following list of areas of expertise, interest or let us know how you

would like to volunteer your time.

___ Chaperones for special events ___ Building Maintenance*

___ School Mailings ___ Tutoring*

___ Fundraising ___ Cafeteria Aides*

___ Advertising ___ Club Sponsors*

___ Field Trips ___ Special Presentations

___ Special Projects* ___ Parent/Teacher Conference Lunch

___ Classroom Aides*/Homeroom Parent* ___ Staff Appreciation Week (May)

___ Parent Teacher Student Association (PTSA) ___ Carnivals

___ Parking Lot Duty* ( AM/PM) ___ Copy Parent*

___ Book Fair ___ Concessions During Performances

___ School Dances ___ Other:____________________

*May require state issued Fingerprint Clearance Card – if needed we can provide information on how to get one.

I have a current Arizona State issued Fingerprint Clearance Card ___ Yes ___ No

______________________________________ __________________ Student Name Grade _________________________ ___________________________ Day Phone Number Evening Phone Number _____________________________________ email address ______________________________________ Parent Name __________________________________________ ____________ Parent Signature Date


Annual Notification for Parents: FERPA

Annual Notification to Parents Regarding Confidentiality of Student Education Records

The Family Educational Rights and Privacy Act (FERPA) is a Federal law that protects the privacy of student education records. FERPA gives

parents certain rights with respect to their children's education records. These rights transfer to the student when he or she reaches the age of 18 or attends a school beyond the high school level. Students to whom the rights have transferred are "eligible students."

Parents or eligible students have the right to inspect and review the student's education records maintained by the school within 45 days

of a request made to the school administrator. Schools are not required to provide copies of records unless it is impossible for parents or

eligible students to review the records without copies. Schools may charge a fee for copies.

Parents or eligible students have the right to request in writing that a school correct records that they believe to be inaccurate or

misleading. If the school decides not to amend the record, the parent or eligible student then has the right to a formal hearing. After the

hearing, if the school still decides not to amend the record, the parent or eligible student has the right to place a statement with the record setting forth his or her view about the contested information.

Generally, schools must have written permission from the parent or eligible student in order to release any information from a student's

education record. However, FERPA allows schools to disclose those records, without consent, to the following parties or under the

following conditions:

o School officials with legitimate educational interest

A school official is a person employed or contracted by the school to serve as an administrator, supervisor, teacher or

support staff member (including health staff, law enforcement personnel, attorney, auditor or other similar roles); a

person serving on the school board; or a parent or student serving on an official committee or assisting another school

official in performing his or her tasks;

A legitimate educational interest means the review of records is necessary to fulfill a professional responsibility for

the school;

o Other schools in which a student is seeking to enroll;

o Specified officials for audit or evaluation purposes;

o Appropriate parties in connection with financial aid to a student;

o Organizations conducting certain studies for or on behalf of the school;

o Accrediting organizations;

o To comply with a judicial order or lawfully issued subpoena;

o Appropriate officials in cases of health and safety emergencies; and

o State and local authorities, within a juvenile justice system, pursuant to specific State law.

Schools may disclose, without consent, "directory" information such as a student's name, address, telephone number, date and place of birth, honors

and awards, sports participation (including height and weight of athletes) and dates of attendance unless notified by the parents or eligible student

that the school is not to disclose the information without consent.

The Individuals with Disabilities Education Act (IDEA)

The Individuals with Disabilities Education Act (IDEA) is a federal law that protects the rights of students with disabilities. In addition to standard

school records, for children with disabilities education records could include evaluation and testing materials, medical and health information,

Individualized Education Programs and related notices and consents, progress reports, materials related to disciplinary actions, and mediation

agreements. Such information is gathered from a number of sources, including the student's parents and staff of the school of attendance. Also, with

parental permission, information may be gathered from additional pertinent sources, such as doctors and other health care providers. This

information is collected to assure the child is identified, evaluated, and provided a Free Appropriate Public Education in accordance with state and

federal special education laws.

Each agency participating under Part B of IDEA must assure at all stages of gathering, storing, retaining and disclosing education records to third

parties that it complies with the federal confidentiality laws. In addition, the destruction of any education records of a child with a disability must

be in accordance with IDEA regulatory requirements.

For additional information or to file a complaint, you may call the federal government at (202) 260-

3887 (voice) or 1-800-877-8339 (TDD) OR the Arizona Department of Education (ADE/ESS) at

(602) 542-4013. Or you may contact: Family Policy Compliance Office U.S. Department of

Education 400 Maryland Avenue, SW Washington, D.C. 20202-5901

Arizona Department of Education

Exceptional Student Services

1535 W. Jefferson, BIN 24

Phoenix, AZ 85007

School Law News The January 14, 2013 , enactment of the Uninterrupted Scholars Act (Public Law 112-278) now permits educational agencies

and institutions to disclose a student's education records, without parental consent, to a case worker or other representative of a State or local child

welfare agency or tribal organization authorized to access a student's case plan, "when such agency or organization is legally responsible, in

accordance with State or tribal law, for the care and protection of the student." In addition, in certain judicial proceedings, a school may disclose

student's educational records, pursuant to a court order, without notifying the student's parents.



McKinney-Vento Eligibility Questionnaire

Name of School: Arizona Conservatory for Arts & Academics

Name of Student:_____________________________________________________ Male

Last First Middle Female

Birth Date____/____/_______ Age:_______ Month/Day/Year

This questionnaire is intended to address the McKinney-Vento Act 42 U.S.C. 11435. The answers to this

residency information help determine the services the student may be eligible to receive.

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

Parent/Guardian Intials:______________ Date:________________

If you answered YES to the above questions, please complete the remainder of this form.

If you answered NO, you may stop here.

Where is the student presently living? (Check one box.)

In a motel In a shelter With more than one family in a house or apartment Moving from place to place In a place not designed for ordinary sleeping accommodations (ex. car, park, campsite) Other______________________

Name of Parent(s)/Legal Guardians(s)_______________________________________________

Address____________________________________Zip___________Phone________________

Signature of Parent/Legal Guardian_____________________________Date________________

Office Use only

I certify the above named student qualifies for the Child Nutrition Program under the provisions of the McKin-

ney-Vento Act.

________________________ ____________________________________________

Date McKinney-Vento Liaison Signature


State of Arizona

Department of Education Office of English Language Acquisition Services

Primary Home Language Other Than English (PHLOTE)

Home Language Survey (Effective April 4, 2011)

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

Responses to these statements will be used to determine whether the student will be assessed for English Language

Proficiency.

1. What is the primary language used in the home regardless of the language spoken

by the student? __________________________________________________________

2. What is the language most often spoken by the student? _______________________

3. What is the language that the student first acquired? __________________________

Student Name ______________________________________ Student ID __________________

Date of Birth _____________________________________ SAIS ID ______________________

Parent/Guardian Signature __________________________________ Date _________________

District or Charter _________________EdKey Inc__________________________________

School _________________Arizona Conservatory for Arts & Academics__________

------------------------------------------------------------------------------------------------- -------------------------------------------

Please provide a copy of the Home Language Survey to the ELL Coordinator/Main Contact on site.

In SAIS, please indicate the student’s home or primary language.

1535 West Jefferson Street, Phoenix, Arizona 85007 • 602-542-0753 • www.azed.gov/oelas

http://www.azed.gov/oelas


Estado de Arizona

Departamento de Educación Servicios de Aprendizaje del Inglés

Idioma Principal en el Hogar excluyendo el inglés (PHLOTE)

Encuesta sobre el Idioma en el Hogar (Efectivo el 4 de abril de 2011)

Preguntas en conformidad con R7-2-306(B)(1), (2)(a-c) del Reglamento de la Junta Directiva.

Las respuestas que proporcione a las preguntas siguientes serán usadas para determinar si se evaluará la competen-

cia en el idioma inglés de su hijo(a).

1. ¿Cuál idioma se habla principalmente en su hogar sin considerar el idioma que habla el estudiante?

________________________________________________________________

2. ¿Cuál idioma habla el estudiante con mayor frecuencia? __________________________

3. ¿Cuál fue el primer idioma que aprendió el estudiante? ___________________________

Nombre del estudiante ___________________________ Núm. de identificación _____________

Fecha de nacimiento __________________________ Núm. de SAIS ______________________

Firma del padre o tutor ____________________________________ Fecha _________________

Distrito o Charter ___________________ EdKey Inc ________________________________

Escuela ________Arizona Conservatory for Arts & Academics____________________

----------------------------------------------------------------------------------------------------------------------------- ---------------

Please provide a copy of the Home Language Survey to the ELL Coordinator/Main Contact on site.

In SAIS, please indicate the student’s home or primary language.

1535 West Jefferson Street, Phoenix, Arizona 85007 • 602-542-0753 • www.azed.gov/oelas


Arizona Department of Education

Arizona Residency Documentation Form

Student________________________________ School ____ACAA Elementary (Redwood)____

School District or Charter Holder ____________EdKey Inc_________________________________

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 U.S. passport

___ 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 or other identification issued by a recognized Indian tribe that contains an Arizona

address.

___ Documentation from a state, tribal or federal government agency (Social Security Administration, Veteran’s Ad-

ministration, Arizona Department of Economic Security)

___ 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

#2306606


State of Arizona

Affidavit of Shared Residence

I swear or affirm that I am a resident of the State of Arizona and that the persons listed below reside with me at my

residence, described as follows:

Persons who reside with me:

_____________________________________________________________________________

______________________________________________________________________________

Location of my residence:

____________________________________________________________________________________

I submit in support of this attestation a copy of the following document that displays my name and current residence

address or physical description of my property: ___ Valid Arizona driver’s license, Arizona identification card or motor vehicle registration

___ Valid U.S. passport

___ 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 or other identification issued by a recognized Indian tribe.

___ Documentation from a state, tribal or federal government agency (Social Security Administration, Veteran’s

Administration, Arizona Department of Economic Security)

Printed Name of Affiant: ______________________________

Signature of Affiant: ______________________________

Acknowledgement State of Arizona

County of Maricopa

The foregoing was acknowledged before me this ____ day of _______________, 20____,

By ____________________________________. _______________________________

Notary Public

My Commission Expires:

_____________________ #2306606

Documents

Elementary School Enrollment Check List Elementary...Revised 1/6/17 ACAA Enrollment 2017-2018 Elementary School Enrollment Check List The following items must be turned in before your