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DEER VALLEY UNIFIED SCHOOL DISTRICT #97 STUDENT REGISTRATION

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DEER VALLEY UNIFIED SCHOOL DISTRICT #97
STUDENT REGISTRATION FORM
STUDENT'S LEGAL NAME: ___________________________________________________________________________________
AGE: _________ SEX: _________ GRADE: _________
ETHNICITY:
(check one) ❑ Hispanic or Latino ❑ NOT Hispanic or Latino
RACE:
(Please check all that apply and circle the primary race) ❑ White ❑ Black / African American ❑ Asian ❑ Native Hawaiian / Other Pacic Islander
❑ American Indian / Alaskan Native ❑ Afliation & Tribal Name: _______________________________________________
ADDRESS: ___________________________________ CITY:_______________ ZIP:________ PRIMARY #: __________________
DATE OF BIRTH: ________________________ STATE /COUNTRY OF BIRTH: __________________________________________
PARENT/LEGAL GUARDIAN EMAIL ADDRESS:_________________________________________________________
STUDENT LIVES WITH:
❑ Parent/Legal Guardian (Father) List “other” non-legal guardians on Student Health and Release information card
LEGAL NAME:________________________________ CELL #:______________ HOME #:______________ WORK #:_____________
STUDENT LIVES WITH:
❑ Parent/Legal Guardian (Mother) List “other” non-legal guardians on Student Health and Release information card
LEGAL NAME:________________________________ CELL #:______________ HOME #:______________ WORK #:_____________
Child with a parent who is a member of the Armed Forces on active duty
(includes a parent who serves on full-time National Guard Duty):
❑ Yes ❑ No
LEGAL CUSTODY (Check one only)
PARENT/LEGAL GUARDIAN If divorced or separated - court documents must be on le at school
DIVORCED:
❑ Yes ❑ No
Child is in foster care:
❑ Yes ❑ No
Has child previously attended a school in Deer Valley District? _____ Which one: ____________________ When: ____________
SCHOOL PREVIOUSLY ATTENDED: _____________________________ PHONE #: ______________________________________
ADDRESS/
CITY/STATE/ZIP: ______________________ ______________________________________ YRS. ATTENDED: ________
Years of school attended including kindergarten: AZ __________ US __________ Last grade attended:________________
Is the above named child:
Yes ____ No ____ Expelled or being considered for expulsion from any school or district?
Yes ____ No ____ Long-term suspended or being considered for suspension from any school or district?
(Long-term suspension is 11 or more days)
Yes ____ No ____ N/A ____ In compliance with conditions imposed by a juvenile court?
Special classes student has attended: ❑ ESL ❑ Gifted
Does the student currently have an IEP (Individual Education Plan)? Yes ____________ No ____________
Does the student currently have a 504 Accommodation Plan? Yes ____________ No ____________
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 rst acquired? _______________________________________________________________
4) Do you have an I-94? ________ If yes, please provide a copy.
If a language other than English is indicated on this form, your child will be tested for English prociency.
Student has a medical condition: ❑ Yes ❑ No
Please provide further information on the Student Health Information and Medical History Form.
Please indicate how you heard or where you read about your DVUSD School:
❑ Postcard ❑ Neighborhood School ❑ Magazine Ads/Newspaper Ads ❑ Friend/Family Member ❑ Website/Internet Search
PARENT'S/LEGAL GUARDIAN'S SIGNATURE: _____________________________________________ DATE: __________
SCHOOL: __________________________ TEACHER: ______________________ ROOM #: _________ RECORDS REQ: ______
IMM: _____________ B/C: ___________ LEGAL PAPERS:_______________ POR:________________ PR-LNG
OPEN ENROLLMENT ____________________ AREA BREAKDOWN: _______________ ENTRY CODE: _____________________
ENROLLMENT DATE _______________ DATE ENTERED SIS _______________ REGISTRAR __________________________
LAST FIRST MIDDLE
DVUSD (Rev. 03/2019) CATALOG NO. 00200
FOR OFFICE USE ONLY
STUDENT ID #
STATE ID #
DEER VALLEY UNIFIED SCHOOL DISTRICT #97
STUDENT REGISTRATION FORM
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Office of English Language Acquisition Services
1535 West Jefferson Street, Phoenix, Arizona 85007 • (602) 542-0753 • www.azed.gov/oelas
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?
District
Student Name Student ID
Date of Birth SSID
Parent/Guardian Signature Date
District or Charter
School
-------------------------------------------------------------------------------------------------------------------------------------------
Please provide a copy of the Home Language Survey to the EL Coordinator/Main Contact on site.
In AzEDS, please indicate the student’s home or primary language.
(Revised 01-2019)
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April 2019
McKinney-Vento Eligibility Questionnaire
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. The student lives with:
____ Parent(s)/legal guardian(s)
____ An adult who is not the parent/legal guardian
____ No adult; student is unaccompanied youth
____ Student is an adult living on his/her own
2. Check any that apply.
SECTION A
In a foster/group home
Doubled up with relatives or friends due to loss of housing or economic hardship
Youth living with friends or family members (other than parent/guardian)
Living temporarily in hotel/motel
In a shelter
Living in car, campground, trailer etc. Notes_________________________________
If you checked a box in Section A, complete this form and the Deer Valley Student Registration Packet.
SECTION B
Choices in Section A do not apply
If you checked this box, it is not necessary to complete this form. Continue with Deer Valley Student
Registration Packet
Please Print:
Name of Student: ____________________________________________________________________________
Birth Date: ______ /______ /______ Age: _______ Grade in School _______
Month / Day / Year
School Most Recently Attended: _________________________________________________________________
Name of Parent(s)/Legal Guardian: _______________________________________________________________
Temporary/Current Address: ____________________________City:_______ZIP:_______Phone______________
Signature of Parent/Legal Guardian: ______________________________________ Date__________________
DVUSD Enrolling School: ______________________________________________________________________
Registrar: If an option in Section A is checked, please scan and email completed form to:
tricia.brenden@dvusd.org, Deer Valley Unified School District Homeless Liaison. The original form
is kept at the registering campus for audit purposes.
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Arizona Department of Education
Arizona Residency Documentation Form
REVISED 5/21/2019
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.
Deer Valley Unified School District
State of Arizona
Affidavit of Shared Residence
REVISED 5/21/2019
Student Name:
Parent/Legal Guardian Name:
School Name:
School District or Charter Holder:
Name of Arizona Resident:
I, (resident name) 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 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)
Printed Name of Affiant:
Signature of Affiant:
Acknowledgement
State of Arizona County of
The foregoing was acknowledged before me this day of , 20 ,
By
My Commission Expires:
Notary Public
Deer Valley Unified School District
Documents required if address changed
1.Name and relationship to student:
Phone contact:
2.Name and relationship to student:
Phone contact:
3.Name and relationship to student:
Phone contact:
4.Name and relationship to student:
Phone contact:
5.Name and relationship to student:
Phone contact:
Individual(s) Current Record
I AUTHORIZE the following individuals to pick up and assume responsibilty for the above named student.
Current Record
Parent/Legal Guardian
Home Phone
Cell/Text Alert
Work Phone
Parent/Legal Guardian
Home Phone
Cell/Text Alert
Work Phone
General Information Current Record Corrections
Grade Level: HR:
Mailing Address:
Legal Parent/Guardian Information Documents required if custody changed
OTHER CHILDREN & AGES IN FAMILY:________________________________________________________________________
To the best of my knowledge, this student does not have any health problems that would be harmful to him/her while participating in
Physical Education or would require a physical exam. The high schools have a Limited Lifetime Sports Class for short or long-term
disabilities.
I have listed any health conditions and/or required medication for this student on the reverse side of this form.
BE IT KNOWN that I, the undersigned parent or legal guardian of the student named above, do hereby give and grant unto any medical
doctor or hospital my consent and authorization to render such aid, treatment or care to said student as, in the judgment of said doctor or
hospital may be required, on an emergency basis, in the event said student should be injured or stricken ill.
IT IS HEREBY understood that the consent and authorization hereby given and granted are continuing, and are intended by me to extend
through the current school year.
IT IS FURTHER understood that any expenses incurred will be paid by insurance or the parent of the student. Payment of the expense is
not a school responsibility. Forms to purchase Student Accident Insurance are available at the school.
BE IT KNOWN THAT I, THE UNDERSIGNED PARENT/LEGAL GUARDIAN OF THE STUDENT NAMED ABOVE, UNDERSTANDS
THAT I NEED TO UPDATE THIS FORM FOR THIS STUDENT WHEN ANY CHANGES ARE MADE RELATING TO HEALTH,
RESIDENCY, PHONE NUMBERS AND EMERGENCY CONTACTS.
Signature required:____________________________________________________Dated:____________
The above signature acknowledge that I have read and consent to the above.
PLEASE COMPLETE REVERSE SIDE
Gender: Birth Date:
Physical Address:
Primary Phone Number:
Primary Parent/Guardian Email Address:
Name:
Student Emergency Contact Information Form
Please read the information below and write any corrections to the right of each answer in the "Corrections" column
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Name: Grade: HR Teacher:
Has your child had chicken pox? Yes _____ at what age? __________ No _____
IF YOUR CHILD HAS NO CURRENT, ACTIVE MEDICAL CONDITIONS OR SIGNIFICANT
MEDICAL HISTORY, THAT COULD POTENTIALLY IMPACT HIS/HER DAY AT SCHOOL,
PLEASE INITIAL HERE ____________
Student Health Information and Medical History
Known vision problem: ______________________________ Wears glasses? ______ Contact lenses? ______
Known hearing loss: ____________________________________________________ Hearing Aid? _______
ALLERGIES Please explain details of any allergy that your child has.
Bee Sting: __________________________________________________________________________
Food: __________________________________________________________________________
Latex: __________________________________________________________________________
Medications: __________________________________________________________________________
Seasonal: __________________________________________________________________________
Other: __________________________________________________________________________
HEALTH CONDITIONS (List medication and circle home (H) or school (S) or both (HS)
ADD/ADHD: ____________________ Medication: _____________________________________H S
Asthma: ____________________ Medication: _____________________________________H S
Heart Condition: ____________________ Medication: _____________________________________H S
Diabetic: ____________________ Medication: _____________________________________H S
Seizure Disorder: ____________________ Medication: _____________________________________H S
OTHER HEALTH CONDITIONS AND/OR HISTORY
Please list any/all significant health conditions and/or history: ______________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
OTHER MEDICATIONS taken by your child, please list and circle home (H) or school (S) or both (HS):
________________________________________ H S ________________________________________ H S
________________________________________ H S ________________________________________ H S
________________________________________ H S ________________________________________ H S
________________________________________ H S ________________________________________ H S
Written consent to administer medication at school must be given by parent/legal guardian. Students are not
permitted to carry/possess medication at school, or to and from school. Exceptions must be arranged by
parents through the nurse in accordance with Deer Valley Unified School District Policy and Procedures.
DVUSD does not stock or provide any medication for students.
Please see the nurse at school if health or medical information changes for your child.
Rev. 5/11/20
2020-2021
STUDENTS RIGHTS & RESPONSIBILITIES
ACKNOWLEDGMENT & VERIFICATION
STUDENT’S NAME: (PLEASE PRINT)
STUDENT I.D # GRADE:
TEACHER’S NAME: SCHOOL:
This Acknowledgment & Verification signature page is to be returned to each child’s school by Friday,
August 14, 2020.
The Deer Valley Unified School District is dedicated to contributing to a sustainable future for our
planet through reducing consumption, reusing what we have and recycling what we can. This
philosophy includes conserving natural resources. To support this, in lieu of printing a copy of the
2020-2021 Student Rights & Responsibilities Handbook for every student and staff member in our
district, the 2020-2021 handbook will be available on our website, in both English and Spanish at
www.dvusd.org. If you don’t have access to the internet, please contact your child’s school to request
that a printed copy of this important handbook be sent home with your child.
By signing this form you are acknowledging and verifying that you have read and reviewed with your
child/children the Student Rights & Responsibilities Handbook. As a parent in the Deer Valley Unified
School District, you have the right to a quality education for your child/children. To make sure that
every student enjoys that right, the District has established procedures regarding disruptive behavior.
The procedures for student responsibility are designed to create an orderly environment that is safe
for all students and staff. The rules are reasonable and fair and they are the same at each school.
We ask that you read carefully the infractions and disciplinary actions for conduct with your child.
Parent/Guardian Name Printed Parent/Guardian Signature Date
Directory, Internet, and E-Mail User Agreement
Grade Level K-8
STUDENT’S NAME (PLEASE PRINT)
STUDENT I.D.# SCHOOL:
PARENT’S/GUARDIAN’S NAME: (PLEASE PRINT)
NOTICE TO PARENTS REGARDING DIRECTORY INFORMATION:
According to state and federal law, directory information may be publicly released to an institution of higher learning (community colleges,
universities, trade schools) or military representatives. Directory information may consist of the student’s name, grade level, address and
phone number, dates of attendance, enrollment status, participation in officially recognized activities and sports, weight and height (if a
member of an athletic team), honors and awards received, date and place of birth, and image in photographs or video.
Please note the following statement from the U.S. Department of Education: “Recognizing the challenges faced by military recruiters,
Congress recently passed legislation that requires high schools to provide to military recruiters, upon request, access to secondary school
students and directory information on those students. Both the No Child Left Behind Act of 2001 and the National Defense Authorization
Act for Fiscal Year 2002 reflect these requirements. In accordance with those Acts, military recruiters are entitled to receive the name
and address listing of juniors and seniors in high school.”
Family Educational Rights and Privacy Act (FERPA) allows schools to disclose directory information without consent to the following
parties or under the following conditions:
• School officials with legitimate educational interest;
• Other schools to which a student is transferring;
• Specified officials for audit or evaluation purposes;
• Appropriate parties in connection with financial aid to a student;
• Organizations conducting certain studies for or on behalf of the school;
• Accrediting organizations;
• To comply with a judicial order or lawfully issued subpoena;
• Appropriate officials in cases of health and safety emergencies; and
• State and local authorities, within a juvenile justice system, pursuant to specific state law.
You are required to initial beside only ONE of the following statements:
______ I give consent to DVUSD to release Directory Information regarding my child for non-commercial purposes. (This includes
permission for your child to participate in individual and class photos, appear in the yearbook, promoted through school and district
publications for awards, special recognitions, sports and extracurricular activities.)
_______ I do not give consent to DVUSD to release Directory Information regarding my child for the following: (check all that apply)
_____ My child’s photo to be taken individually or in class photo and published in the school yearbook.
_____ My child’s photo to be published in school or district publications including the student newspaper, local newspapers,
publications for awards, special recognitions, or sports and extracurricular activities.
If the school district does not receive this notification from you within two weeks of receipt of this notice, it will be assumed
that your permission is given to release your child’s directory information. Please be assured that your child’s safety and welfare
are our primary concerns. As in the past, we will be prudent and cautious in all of our practices regarding this issue. If you wish to make
a change to your choice above, you can do so at any time by contacting your child’s school. This form will remain in effect until an
updated form is filled out and returned to your child’s school.
CONTINUED ON NEXT PAGE
Page 1 of 3
Rev. 5/24/17
Page 2 of 3
NOTICE TO PARENTS REGARDING INTERNET AND EMAIL USER AGREEMENT:
The DVUSD Network is provided for students/users to conduct research and communication for academic purposes only
as determined by the District curricula. Independent access to network services is provided to students/users who agree
to act in a considerate and responsible manner. Access is a privilege, not a right, and entails responsibility. Students are
responsible for appropriate behavior/communication on school computer networks, just as they are in classrooms or
school buildings. Network storage areas may be treated like school lockers. All network administrators/teachers may
review files and communications to maintain system integrity and ensure responsible use of the Internet by requesting a
search history of websites visited to ensure that such use meets the District’s intent as a tool for academic purposes.
Files stored on District servers are not private. Communications are public and often uncensored and students may
come in contact with materials that are controversial or inaccurate from all around the world. The District uses an
internet filtering mechanism that promotes the safety and security of the use of the District’s online computer network
when using electronic mail, chat rooms, instant messaging, and other forms of direct electronic communications. The
District is not responsible for the accuracy or appropriateness of information retrieved, or for lost, damaged or
unavailable information. Outside of school, families must bear the responsibility for such guidance as they also must do
with information sources such as television, telephone, movies, radio and other potentially offensive media. Parents
may revoke their students’ Internet/E-Mail privileges at any time by notifying the school in writing.
The following are not permitted:
1. Send, access, download or display offensive messages or pictures
2. Use obscene, profane, lewd, vulgar, rude, inflammatory, threatening, or disrespectful language
3. Harass, insult or attack others
4. Damage computers, systems or networks
5. Violate copyright laws and regulations
6. Use passwords of others
7. Share passwords with others
8. Trespass in others’ folders, work or files
9. Employ the network for commercial purposes
10. Provide personal information, i.e., names, addresses, phone numbers, card numbers, etc.
11. Tamper as defined in A.R.S. 13-2316 and as described under the infraction Computer/Network
Infraction/Telecommunication Device and in the DVUSD Student Rights and Responsibilities handbook
12. Students may not install, copy, or download games, music, movies, and any unauthorized software or violate
any copyright laws
13. Post chain letters or engage in “spamming”
14. Gain unauthorized access to District network resources
Sanctions:
1. Violations of this Internet and Email User Agreement may result in a loss of access
2. Violations of this Internet and Email User Agreement may be subject to disciplinary action including
expulsion/dismissal
3. When applicable, law enforcement agencies will be involved
CONTINUED ON NEXT PAGE
Rev. 5/24/17
Page 3 of 3
NOTICE TO K-8 PARENTS REGARDING COPPA COMPLIANCE INFORMATION:
Deer Valley Unified School District utilizes several computer software applications and web-based services operated by
third parties. In order for our students to use these programs and services, certain basic information (generally student
name, username, and email address) must be provided to the website operator. Under the federal Children’s Online
Privacy Protection Act (COPPA) law, these websites must notify parents and obtain parental consent before collecting
information from children under 13 years of age. For more information on COPPA, please visit
http://www.ftc.gov/privacy/coppafaqs.shtm
.
The law permits schools, such as those in DVUSD, to consent to the collection of this information on behalf of all of its
students, thereby eliminating the need for individual parental consent given directly to each website provider. When
email addresses are utilized, it is important to note that students in grades K-8 can only email DVUSD staff members
from their school accounts and cannot receive email from any outside email address. Outside individuals and companies
will not be able to communicate with children in these grades.
Under the Children's Online Privacy Protection Act (COPPA), verifiable parental consent is required for students under
the age of thirteen (13) if accounts containing this information are created for them on third party websites or online
services. Limited information for your child consisting of first name, last name, birth date, username and email address
may be provided to the online resource for the purpose of securing confidential credentials and access for the student.
This information will remain confidential and will not be shared except for providing online programs solely for the
benefit of students and the school system. Under no circumstances are third party websites authorized to use student
information for commercial purposes.
By not signing the Internet and E-Mail User Agreement, you must be aware that your child:
1. May observe other students using the Internet
2. May witness classroom teachers using the Internet as an instructional tool
3. May witness other campus staff using the Internet for instructional purposes (Ref. DVUSD Policy IJNDB)
4. Will not be able to use Wi-Fi enabled technology to access curriculum and other instructional materials
5. May take required state assessments on Wi-Fi enabled technology using a secure browser
By signing the DVUSD Directory, Internet, and E-Mail User Agreement, you agree to the terms and conditions listed
above for the duration of the student’s enrollment in Deer Valley Unified School District or until directory selection or
internet/E-mail privileges are revoked by the parent/guardian in writing.
Student’s Name (Please Print)
________________________________________________________ ______________________________
Parent/Guardian Signature Date
________________________________________________________ ______________________________
Student Signature Date
Rev. 5/24/17
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DEER VALLEY UNIFIED SCHOOL DISTRICT 97 STUDENT REGISTRATION

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Completed 16 February 2021

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