Fillable 2018 Returning Student Reg Packet

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2018 Returning Student Reg Packet

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  • 121 check-boxes
  • 235 other fields

Country of origin: US
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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
AMPHITHEATER SCHOOL DISTRICT
HEALTH INFORMATION CARD
Revised 1/18 Stock Form #W9072
Full Legal Name of Student________________________________________________________________ Sex______ Grade______ School_________________
(Last) (First) (Middle) (M/F)
Resident Address______________________________________________________________________________________________________________________
Mailing Address (if different) ___________________________________________________________________________________________________________
Date of Birth __________________ Place of Birth_________________________________________________________________________________________
City State Country
Name/Address of Person(s) with whom Student may reside:
Name Address (If different than above) Home # Work # Cell #
Father _________________________________________ _______________________________________ ____________ ____________ ____________
Step-Father _____________________________________ _______________________________________ ____________ ____________ ____________
Mother ________________________________________ _______________________________________ ____________ ____________ ____________
Step-Mother ____________________________________ _______________________________________ ____________ ____________ ____________
Guardian ______________________________________ _______________________________________ ____________ ____________ ____________
Brothers/Sisters:
Name __________________________ Age _____ School ________________ Name __________________________ Age _____ School _________________
Name __________________________ Age _____ School ________________ Name __________________________ Age _____ School _________________
Name __________________________ Age _____ School ________________ Name __________________________ Age _____ School _________________
Any legal restricted custody decision the school health ofce should be aware of? If yes, describe: ____________________________________________________
Language(s) spoken by Student _______________________________________ Language(s) spoken at home _______________________________________
PLEASE PRINT
TEACHER'S NAME ___________________
PLEASE CHECK THE FOLLOWING ITEMS, IF THEY PERTAIN TO YOUR STUDENT:
qADHD/ADD q Allergies/drug q Allergies/food q Asthma q Birth defects q Blood disorder q Bowel/bladder
q Diabetes q Glasses/contacts q Headaches/migraines q Hearing problem q Heart condition q Orthopedic q Psychiatric disorder
q Seizure disorder q Other (If any items were checked, please explain) ________________________________________________________________
If your student is to take medication at school, a signed consent form is required.
Please list all medication(s) student is now taking at home or school: ____________________________________________________________________________
What health or physical problem might affect school attendance or participation in PE? _____________________________________________________________
Has your student ever been involved in a special education program? If yes, please explain __________________________________________________________
INSURANCE COVERAGE: q None q AHCCCS q Kids Care q Indian Health Services q Other Health Plan _________________________________
Doctor ________________________________________________ Phone _______________________ Hospital Preference ______________________________
If parent/guardian cannot be reached, name a relative or friend with a LOCAL PHONE who will be responsible for your student if he/she is hurt or becomes
ill at school. (Please notify the school health ofce of any information changes on this card.
Name ______________________________________________ Address ______________________________________ Phone(s) __________________________
Name ______________________________________________ Address ______________________________________ Phone(s) __________________________
If emergency medical action or treatment is required, and parent/guardian cannot be contacted, I hereby authorize my child to be given emergency medical care as
deemed necessary by school ofcials. I understand that any expenses incurred will be paid for by the parent/guardian or by insurance coverage provided by the parent/
guardian, and that payment of any medical expense is not the responsibility of the school or the school district.
Parent/Guardian Signature _______________________________________________________________________ Date _________________________________
(Signature veries that all of the information on this card is accurate.)
Amphitheater Unied 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/afliation, 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.
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School communication is distributed via email . Newsletters, Special Notices, Bus
Information, etc. will be emailed to you. Therefore, we are requesting your email
address. If you do not have an e-mail address we are requesting that you visit the
Mesa Verde Website http://www.amphi.com/MesaVerde
for information regarding
events, updated news and other information about Mesa Verde Elementary School.
Thank You,
Student’s name:__________________________________________Grade:______
Mother’s name: _____________________________________________________
E-mail address: _____________________________________________________
Father’s Name: _____________________________________________________
Email Adress: ______________________________________________________
Guardian’s Name: ___________________________________________________
Email Address:______________________________________________________
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2018 Returning Student Reg Packet

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Completed 3 July 2020

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