Enrollment Packet - American Leadership Academy

STUDENT ENROLLMENT FORM
FOR OFFICE USE ONLY
Student ID Number
School Name
SAIS ID Number
Teacher
Grade
2350 E Germann Rd #24
Chandler, AZ 85142
(480) 420-2101
www.ALASchools.org
Entry Date
Date Received
Immunizations
Date Received
Student Information
Legal First Name
Gender
Date of Birth
Black
Hispanic
Asian
Birth Country Birth State
Last School Attended
Do you currently have an IEP?
Do you currently have a 504 Plan?
Application Year
2014-15
2015-16
2016-17
City
Yes
No
Yes
No
Suffix
Grade (for application year)
KG -PM
1
2
4
5
KG -Full*
3
6
KG -AM
7
8
9
10
11
12
Other:
American Indian
Name
Proof of Residency
Middle Name
Racial/Ethnic Background
White
Initials
Initials
Birth Cert on Record
Legal Last Name
Nickname/ Goes by
Entry Code
Date Entered in Campus
State
Phone Number
If yes, please attach a copy of the most recent IEP.
If yes, please attach a copy of the most recent 504 plan.
Have you ever been or are you currently pending suspension?
Yes
No
If yes, explain
Have you ever been or are you currently pending expulsion?
Yes
No
If yes, explain
Parent/Guardian Information
Parent/Guardian #1
Last Name
Parent/Guardian #2
Last Name
First Name
Street Address
Street Address
City
State
ZIP
State
City
Relationship to student:
ZIP
Relationship to student:
Emergency
Attendance
General
Emergency
Home Phone
Home Phone
Cell Phone
Cell Phone
Employer
Employer
Work Phone
Work Phone
Email
Email
Custody/Residency Information
Who has legal custody?
Custody Documents
First Name
Attendance
General
Emergency Contacts (other than listed above)
Full Name
Yes
No
Relationship
Yes
No
*Note: The school will not honor requests or restrictions unless copies of custo- Full Name
dy documents and/or copies of court orders that support the request of the parent are on file with the school (ARS 25-408; ARS 25-403.06). A power of attorney Relationship
document can not replace court ordered custody documents (ARS 14-5104)
Non-Custodial Restrictions
Policy Acceptance
I agree to the principles, policies, and requirements outlined in the ALA
student handbook.
I accept the technology use agreement.
I accept the Infinite Campus Portal Use Guidelines
I permit ALA to use media of my student for advertising and promotional
purposes
*A fee may be charged for participation in full day Kindergarten
Phone
Phone
I hereby certify that the information contained in this application is correct and
understand that any misrepresentation or ommission of facts on this application
may result in the immediate nullification of enrollment. I further understand
that the application is not considered complete until all required attachments
are submitted to ALA.
____________________________________________
Parent/Guardian Signature
Page 1
Health Information & Contact Priority
Legal Last Name
Legal First Name
Date of Birth
Physician Information
Grade
Medications
I give consent to the Nurse or Health Assistant to use their discretion to give the
following medication orally or topically:
Primary Physician
Medical Facility/Practice Name
Street Address
City
State
ZIP
Phone
Allergies
Please indicate any allergies the student may have by clicking next to the applicable box(es) below.
Milk
Tree Nuts
Peanuts
Fish
Eggs
Bee Sting
Shellfish
Wheat
Ant Bite
Red Dye
Other:
Does your child require an
Epi-Pen?
Yes
No
Tylenol (Acetaminophen)
Calamine Lotion
Hydrocortisone/Bactine
Triple Antibiotic Ointment
Tums/Antacid
Eye Wash
Benadryl
Cough Drop/ Lozenges
Sunscreen
Motrin (Ibuprofen)
Burn Cream
Contact Priority
Contact Name
Phone
Priority
Please list below any other health conditions your child may have:
Varicella (Chickenpox)
Students entering school are required by the Arizona Department of Health Services to have proof of Varicella immunization OR indicate a that the student has already
had chickenpox. Please review your student’s record and indicate his/her status below.
Yes, my student has had Chickenpox
Yes, my student has had the Varicella Immunization
No, my student has not obtained the immunization or had Chickenpox. If you need immunizations, please contact your child’s primary care provider or call
Community Information and Referral at 602-263-8856 or find them on the web at www.cirs.org.
Immunizations
Before a child may attend any Arizona school, Arizona law (ARS 15-871; Administrative Code R9-6-701 through 708) requires that an immunization record be presented
to the school or child care staff by the parent/guardian. The immunization record is usually the one given to parents/guardians by their doctor or clinic, and must show
the date each required vaccine dose was received as well as the signature or stamp of the health care provider. Children must obtain required immunization(s) prior to
attending school. If a child requires more than one dose of a specific type of vaccine, the child may continue to attend school during the minimum interval between doses.
Parents may obtain a waiver from immunizations for medical exemptions, personal beliefs, and religious beliefs but must submit the appropriate waiver form prior to
attending school. In the event of a breakout, students with waivers will be required to remain at home. For more information about immunizations, forms, and access to
free immunizations, please visit the AZ Deparment of Health website. Please attach your childs immunization record or the appropriate waiver form below.
When to Stay Home
It is important that the school remain a safe and healty place for both children and adults. Illnesses spread rapidly in the school setting so we ask that if your child
exhibits the following symptoms, that you keep them at home:
1. Fever/Temperature: If your child has a temperature of 100 degrees or higher, keep them home. The student may return after being fever-free for 24 hours.
2. Vomiting/Diarrhea: Please keep your child home until they are symptom-free for 24 hours and are able to resume a regular diet.
3. Pink Eye: Your child may return to school after a full 24 hours of antibiotic.
4. Strep Throat: Your child may return to school after a full 24 hours of antibiotic and fever-free.
5. Lice: Students with lice should NOT attend school until they have been treated and are nit-free.
Medication
Signature & Consent
Please do not send your student to school with medication of any type. All med- I have read and agree to the policies outlined in this document. I have answered
ications must be checked in through the front office, come in the original pack- all questions truthfully and give consent for the administration of the medications
aging, be clearly marked with the student’s name and dosage, have a current indicated on this form.
presription, and be within the expiration date. Parent consent is required for all
medicaitons.
____________________________________________
Page 2
Priority Enrollment
Under A.R.S 15-184, charter schools may extend priority enrollment to children and grandchildren of staff, siblings of students currently attending, and returning students.
Does the applicant have a sibling currently attending an ALA Campus?
Is the applicant the child or grandchild or current ALA staff?
Yes
Yes
No
Yes
No
No
Is the applicant considered homeless under the McKinney-Vento Act?
Advertising
N ot Sure
How did you hear about American Leadership Academy? (Mark all that apply)
Friends or Family
Drove by campus
Previously Attended
ALA Website
Internet Search
Enrollment Event/Meeting
Social Media
Campus Tour
Other
What aspect of American Leadership Academy most influenced your decision to enroll?
Academic Program
Leadership Program
Parent Involvement/Partnership
Fine Arts Program
School Culture/Environment
Proximity to home/convenience
Athletics Program
Teachers/Staff
Other
Campus Selection
Please indicate what campus you are applying for:
Gilbert
Mesa
Queen Creek K-6
Queen Creek 7-12
Anthem South
San Tan Valley
Ironwood K-6 (Opening 2015-16 SY)
Ironwood 7-12 (Opening 2015-16 SY)
Page 3
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 ______________________________________________________________
American Leadership Academy, Inc.
School _______________________________________________________________________
-------------------------------------------------------------------------------------------------------------------------------------------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
School
Student
School District or Charter Holder _____________________________________________
American Leadership Academy, 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 Administration, 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
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