English - Balsz School District

For Office Use Only:
SAIS # _______________________
Perm ID# ___________________
Entry Code: _______
Records Requests:  CUM Records  SpEd – records (if applicable)
Verified:  Birth Certificate  Proof of Address
 Shot Records
Create:
 70 Report
Entry Date: ________________ Date entered in Synergy: _______________________
 CUM File
 Permanent Record Card
 Grade Level: _______
 45-Day Screener to HR Teacher
Assigned HR Teacher: _________________________________________
Balsz School District #31 Enrollment Application
Demographic Information:
Legal Last Name: ________________________________________________ First Name: ____________________________________ Middle Name: __________________ Grade: ______
 Male
 Female
Date of Birth: _________________________ Place of Birth: _______________________________ Date entered U.S. School: _____________________
Home Address: ________________________________________________________________________________________________ Home phone: _______________________________
Parent/Guardian Email: _____________________________________________ Parent/Guardian cell: ______________________________ Message phone: _______________________
Check all that apply:
 Receive hard copy mailings
 Receive Email messages
 Receive Text message (cell phone charges may apply, please see your provider service contract)
With whom does the student live? (Mother, Father, Step-Mother, Step-Father, or Guardian):
Name ____________________________________________________________ Relationship to Student ___________________________________ Cell _____________________________
Name ____________________________________________________________ Relationship to Student ___________________________________ Cell _____________________________
Who has legal custody of child? _______________________________________ Relationship________________________ Does the other parent have visitation rights?  Yes
*Note: The school will not honor requests of restrictions unless copies of custody papers or court orders (that support the requests of the parent) are on file with the school.
 No
Emergency Contact Information – Name(s) of person to contact if parent/guardian is not available:
Name _______________________________________________________________ Relationship to Student _________________________ Phone/Cell: _____________________________
Name _______________________________________________________________ Relationship to Student _________________________ Phone/Cell: _____________________________
Health Office Information:
Specify health problems or allergies (including food or medication):
__
Is your child on daily medications?:  No  Yes – please list medications: ____________________________________________________________________________________________
Any recent surgery, hospitalization, accident or illness in the past year?:  No  Yes - ___________________________________________________________________________________
Ethnicity: Is the student Hispanic/Latino:  Yes
 No
Race: (check all that apply)  White
 Black or African American
 Asian
 American Indian or Alaska Native
 Native Hawaiian or Other Pacific Islander
Language Survey:
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: _________________________
Preferred language for communications:
 English
 Spanish
 Other: _________________________
Background Information:
Has the student been identified for Special Education?  Yes  No If Yes, which program?  Speech  Resource  Other: ________________ Do you have a copy of the IEP?  Yes  No
Has the student been identified for Gifted Program Services?  Yes
 No
Has the student received ESL or English Language support services?  Yes  No
Has the student been retained?  Yes  No If Yes, what grade: _________
Did the student attend an Early Childhood Program prior to Kindergarten?  Yes  No
If Yes, indicate the number of years he/she attended: _____ Headstart _____ Pre-School: name of Pre-School: _______________________________________________________
Has the student previously attended a Balsz District School?  Yes
 No
If Yes, indicate name of school: _______________________ Dates attended: ______________
Has the student been given a long-term suspension or expelled?  Yes  No If Yes, indicate name of school: ____________________ Date suspended/expelled: ____________
Brothers & Sisters living in the home enrolled in the Balsz School District:
Name: _________________
Grade: _____
School:
 Balsz
 Brunson-Lee
 Crockett
 Griffith
 Orangedale Early Learning Center
Name: _________________
Grade: _____
School:
 Balsz
 Brunson-Lee
 Crockett
 Griffith
 Orangedale Early Learning Center
Name: _________________
Grade: _____
School:
 Balsz
 Brunson-Lee
 Crockett
 Griffith
 Orangedale Early Learning Center
Name: _________________
Grade: _____
School:
 Balsz
 Brunson-Lee
 Crockett
 Griffith
 Orangedale Early Learning Center
Academic History: List previous school(s) that your child has attended – please indicate: Name of School, City, State
Kindergarten:
________________________________________
1st Grade:
How will your child get home After-School?:
 School Bus (adult must pick up Kindergarten
and/or 1st grade students from stop)
 Parent or other adult will pick up from school
Please list the name(s) of persons other than
parent/guardian that will be picking up afterschool:
2nd Grade:
3rd Grade:
4th Grade:
5th
 Daycare Name of Daycare:
Grade:
Phone number:
6th Grade:
________________
 Walking home with a sibling –
Sibling’s name:
7th Grade:
NOTE: Please be on time to pick up your student,
there is no supervision after school.
8th Grade:
Permission to Release Information
 I do  I do NOT
give permission to release my child’s name, photograph and/or film my child for use by the district, individual school websites, or news media for
the purpose of informing the public of programs provided by our schools. Request to exclude student picture(s) from the school yearbook must be made separately, in writing,
to the principal with parent/guardian signature.
I hereby affirm that all above information is correct. I understand that any legal update of the information on this Enrollment form is my responsibility.
Parent/Guardian Signature ___________________________
___________________
Date______________________________
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 ______________________________________________________________
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
EMERGENCY TREATMENT CONSENT
Student Name:
Date of Birth:
Listed below are the usual medication that the nurse’s office has available for use in treating illnesses
and injuries that may occur in school.
Please initial next to each medication you are authorizing school personnel to administer to the
student named above in case of emergency treatment:
_____ Acetaminophen/Tylenol
_____ Burn Spray
_____ Ibuprofen
_____ Antibiotic Ointment
_____ Allergy Syrup
_____ Allergy ointment/ hydrocortisone
_____ Bactine
_____ Eye wash
_____ Benadryl Cream
_____ Throat Spray / Cough drops
_____ Cough/Cold Syrup
_____ Eye drops
_____ Pepto-Bismol
_____ Antacids
_____ Toothache Drops
_____ Anti-Fungal Cream
CONSENT TO EMERGENCY TREATMENT
My child (named above),who is currently enrolled in the Balsz School District, may receive any of the
medications initialed above which the school health office judges as appropriate treatment.
Parent/Guardian Signature:
Date:
Please make sure to notify the Health Office of any allergies, medications, surgeries, hospitalization
or illnesses by completing the enrollment form. If new medical diagnosis is found after enrollment,
contact the School Health Office and the classroom teacher.
Balsz School District #31
4825 East Roosevelt Street, Phoenix, Arizona 85008 | 602.629.6400 phone | 602.629.6470 fax
Transportation Waiver for Kindergarten/1st Grade Students
I understand that as a parent/guardian of a child in Kindergarten or First Grade, that the Balsz School
District requires that:
 I meet my Kindergarten and/or First Grade child at the bus stop in order for them to be
released.
 I am authorizing the Balsz School District to waive the requirement for my child and hereby
consent and waive any and all liability associated with this decision for the Balsz School District
and/or its designated agent.
The name of the child(ren) that may be dropped off at the bus stop without a parent/guardian or
caregiver present:
Name:
Grade:
Teacher:
Name:
Grade:
Teacher:
Name:
Grade:
Teacher:
Name:
Grade:
Teacher:
I have read and understand the notice above.
Parent/Guardian Signature:
Date:
Balsz School District #31
4825 East Roosevelt Street, Phoenix, Arizona 85008 | 602.629.6400 phone | 602.629.6470 fax
Balsz Elementary School District
“Children First “
Residency Questionnaire
4825 E Roosevelt Street, Phoenix, AZ 85008
This questionnaire is intended to address the McKinney-Vento Act 42 U.S.C. 11431-11435. The answers to
this residency information help determine the services the student may be eligible to receive. Eligibility must
be reviewed and reevaluated every school year.
Name of Student _________________________________
 Male
 Female
School of Attendance:
Date of Birth:
Age:
Address:
Grade:
Zip Code:
Phone number:
Message phone:
1. Is the student living in a housing situation that is:
…Fixed (Stationary/not subject to change)  YES
 NO
 YES
 NO
…Regular (used on a nightly basis)
…Adequate (meets physical and psychological needs typically met in a home environment)?
 YES
 NO
2. Is the student currently living with a parent or legal guardian?  YES
 NO
3. Where does the student stay at night?
 In a shelter or Transitional Housing Program
 In a motel/hotel
 Temporarily with more than 1 family in a house, mobile home, or apartment
 Other (Please describe):
By signing below, I attest the above information is accurate and correct:
Print Name of Parent(s)/Legal Guardian(s):
Signature of Parent/Legal Guardian:
Date:
For Office Use Only
I certify the above named student qualifies for the Child Nutrition Program under the provisions of the McKinney-Vento Act.
Date_____________ McKinney-Vento Liaison Signature ____________________________
REQUEST FOR STUDENT EDUCATION RECORDS
Student Name:
Date of Birth:
Parent Name:
Parent Signature:
Requesting records from:
name of School sending request to
Previous School Phone #: _____________________________
School Fax #: _____________________ District:_______________
School Requesting Student Records (please DO NOT SEND Special Education records to School site):

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

Balsz School
4309 E. Belleview St., Phoenix, AZ 85008
Phone: 602.629.6500
FAX: (602) 629-6504
Brunson-Lee School
1350 N. 48th St., Phoenix, AZ 85008
Phone: 602.629.6900
FAX: (602) 629-6904
Crockett School
501 N. 36th St., Phoenix, AZ 85008
Phone: 602.629.6600
FAX: (602) 629-6604
Griffith School
4505 E. Palm Lane, Phoenix, AZ 85008
Phone: 602.629.6700
FAX: (602) 629-6704
 Please send any SPECIAL EDUCATION RECORDS to Student Services Department:
5048 East Oak Street, Phoenix, AZ 85008
Phone: 602.629.6822
FAX: (602) 629-6815
Type of Information Requesting:
o
o
o
o
o
Permanent record data including attendance and academics
General Cumulative data
Health data
Discipline data
Other _____________________________________________________
In making this request, the undersigned agrees that the information received will be used only by the professional school
staff members who are assigned to work with the student in the educational program and not be released to any other
party without prior written consent of the parent/guardian.
School Representative Signature:
Date:
Balsz School District #31
4825 East Roosevelt Street, Phoenix, Arizona 85008 | 602.629.6400 phone | 602.629.6470 fax
Acknowledgement of Handbook Receipt
I have received a copy of the Balsz Elementary School District’s Student-Parent Handbook for the
current year and have taken the time to review and discuss the policies and procedures with my
child. I have placed a particular emphasis upon the guidelines contained within the Balsz School
District’s Governing Board Policies pertaining to Weapons and Drug Possession and guidelines
for Student and Parent Computer and Network Resource Agreement. I have read the Parent
Compact.
My child and I have read and discussed the following handbook provided by the District.
Dated this _______ day of _____________________, 20_____.
Student Name (Please Print)
Student Signature
Parent / Guardian Name (Please Print)
Parent / Guardian Signature
Teacher Name
Grade Level
PLEASE SIGN AND DATE THIS PAGE,
RETURN IT TO YOUR CHILD’S TEACHER DURING THE FIRST WEEK OF SCHOOL
Policy JFAA-EA
ADMISSION OF
RESIDENT STUDENTS
RESIDENCY DOCUMENTATION FORM
Student Legal Name (please print):__________________________________________________
School:________________________________ District: ____Balsz School District__________
Parent/Legal Guardian Name (please print): ___________________________________________
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:

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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 following 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.
 Please attach notarized Affidavit of Shared Residence Form if unable to provide
document listed above
_________________________________________
Signature of Parent/Legal Guardian
____________________________
Date
Policy JFAA-EB
ADMISSION OF
RESIDENT STUDENTS
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:

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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 __________________________________________________.
My Commission Expires
_____________________
______________________________________
Notary Public