Fillable 1819 Registration Form - Fillable Official

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1819 Registration Form - Fillable Official

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Revised 1/17/18
Amphitheater Public Schools - Student Registration Form
School
School Year
Entering Grade Level
for Given School Year
STUDENT INFORMATION (Please PRINT student name exactly as it appears on the birth certificate)
Legal Last Name
Legal First Name
Full Middle Name
Generation
(Jr. III, IV, etc.)
Gender
□ M □ F
Ethnicity:
Hispanic
Race:
(Check
all that
apply)
□
Black / African American
□
White
□
Native Hawaiian / Pacific Islander
□
Asian
□
American Indian / Alaskan Native
Tribal Affiliation and Number
____________________________
Date of Birth (mm/dd/yyyy)
Country of Birth
State of Birth (US only)
Place of Birth (City)
Residential Address: Apt.# City ST Zip
Preferred Mailing Address (if different): Apt.# City ST Zip
For High
School
Student
Email
@
Student
Phone
( ) -
Language (Responses to these statements will be used to determine whether the student will be assessed for English Language Proficiency)
What is the primary language used in the home regardless of the
language spoken by the student?
□
English
□
Spanish
□
Other__________________________
What is the language most often spoken by the student?
□
English
□
Spanish
□
Other__________________________
What is the language that the student first acquired?
□
English
□
Spanish
□
Other__________________________
Parent/Guardian preferred correspondence language?
□English
□Spanish
□Other__________________________
Enrollment History
Has this student ever attended school in Arizona before?
□
Yes
□
No
Has this student ever attended an Amphitheater school any time in the past?
□
Yes
□
No
Last school attended:_________________________________________
□
Public
□
Charter
□
Private
□
Homeschool
Year Grade Level District City State
Special Programs, Accommodations or Services (Check all that apply past or present and provide paperwork.)
□
Special Education
□
504
□
Speech
□
English Language Development
□
Gifted/Accelerated
□
Chronic Illness
□
Other______
Comments:
Other Information (Check all that apply)
□
Active Military Dependent
□
Foster
□
DCS
□
Refugee Status
□
McKinney-Vento/Homeless
□
Open Enrollment
Other Children/Siblings Under 18 Living at this Address
Name (Last Name, First Name)
Date of Birth
School
Grade
Transportation (Students must meet eligibility guidelines as listed in Board Policy. Please see Amphitheater website.)
If riding bus, student will ride:
□
To AND From School
□
To School Only
□
From School Only
Other modes of transportation: □Walk □Bike □Parent Drop Off / Pick Up □Day Care:_________________________________
Office Use
Only
AM Bus#_______ Stop_________
PM Bus#_______ Stop_________
Student ID: ______________________ Entry Code:____________
Data E
ntry Date:___________ Initials of Person Entering Data:__________
Student Name:______________________________ Grade:______
Parent/Guardian Contact #1 (Only contact #1 is the PRIMARY contact and will be contacted first)
□
Mother
□
Father
□
Foster Mother
□
Foster Father
□
Step-Mother
□
Step-Father
□
Guardian
□
Other_________________
Last Name
First Name
Employer
Cell Phone ( ) -
Home Phone ( ) -
Work Phone ( ) -
□
Address same
as the student
Address if different than student: Apt.# City ST Zip
Email:
@
Contact #1 Spoken Language
□
Agrees to be contacted electronically for education items. (Teacher emails, progress reports, etc.)
Check all that apply:
□Can pick up student
□Lives with student
□
Is an
Emergency Contact
□Receives Report Card
□Can have Parent Portal Access
Parent/Guardian Contact #2
□Mother □Father □Foster Mother □Foster Father □Step-Mother □Step-Father □Guardian □Other_________________
Last Name First Name Employer
Cell Phone ( ) - Home Phone ( ) - Work Phone ( ) -
□Address same
as the student
Address if different than student: Apt.# City ST Zip
Email: @
Contact #2 Spoken Language
□Agrees to be contacted electronically for education items. (Teacher emails, progress reports, etc.)
Check all that apply:
□Can pick up student □Lives with student □Is an Emergency Contact
□Receives Report Card □Can have Parent Portal Access
Who has legal custody of the child? □Contact #1 □Contact #2 (Check both if applicable.)
Is there a joint custody or parenting plan in effect? □Yes □No (If yes, plan must be on file with the school.)
Is this student in care of a guardian? □Yes □No (If yes, legal guardianship records must be on file with the school.)
Is there a restraining order in effect? □Yes □No Against: □Mother □Father □Other (Papers must be on file with school.)
Additional Information:
Additional Contact #3
□Mother □Father □Foster Mother □Foster Father □Step-Mother □Step-Father □Guardian □Other_________________
Last Name First Name #3 Spoken Language
Cell Phone ( ) - Home Phone ( ) - Work Phone ( ) -
Check all that apply:
□Can pick up student □Lives with student □Is an Emergency Contact
Additional Contact #4
□Mother □Father □Foster Mother □Foster Father □Step-Mother □Step-Father □Guardian □Other_________________
Last Name First Name #4 Spoken Language
Cell Phone ( ) - Home Phone ( ) - Work Phone ( ) -
Check all that apply:
□Can pick up student □Lives with student □Is an Emergency Contact
I VERIFY ALL OF THE INFORMATION ON THIS FORM IS ACCURATE
Enrolling Parent/Guardian Printed Name Enrolling Parent/Guardian Signature Date
Amphitheater Unified School District does not discriminate on the basis of race, color, religion/religious beliefs, gender, sex, age, national origin, sexual orientation, creed, citizenship status,
marital status, political beliefs/affiliation, disability, home language, family, social or cultural background in its programs or activities and provides equal access to the Boy Scouts and other
designated youth groups. Inquiries regarding the District’s non-discrimination policies are handled at 701 W. Wetmore Road, Tucson, Arizona 85705 by Anna Maiden, Equal Opportunity &
Compliance Director, (520) 696-5164, amaiden@amphi.com, or Kristin McGraw, Executive Director of Student Services, (520) 696-5230, kmcgraw@amphi.com. Revised 1/17/18
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1819 Registration Form - Fillable Official

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Completed 3 July 2020

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