Amphitheater Public Schools Student Registration

STUDENT INFORMATION
Part 1 of 4

3DLQWHG6N\
(OHPHQWDU\


CLICK TO SUBMIT

THIS AREA
FOR OFFICE USE ONLY
Student ID# ____________________________
Grade ____________

Bus Rider Y

AM Bus # __________ Stop _______________

PM Bus # __________ Stop _______________
Data Entry Date _________ Entry Code ______

www.amphi.com

Initials of Person Entering Data _____________

Students LAST Name

Students FIRST Name

_______________________________________

_______________________________________

Middle Name

___________________________

Generation (Jr. III, IV, etc.)

Gender:

Race: (check all that apply)

Grade

________

Ethnicity:

Hispanic

Date of Birth

______________________________

Nickname

Non-Hispanic

________________________________

Former Name
Birth Place

_____________________________

_____________________________

_________________

Black / African American

White
Native Hawaiian/Pacific Islander
Asian
American Indian / Alaskan Native
Tribal Affiliation _______________
Student E-mail

__________ @________________

Student Cell phone

State of Birth

__________________________

_________ Country of Birth __________

Birth Verification Attached

What is the language most often spoken by the student?

_______________________________________

What is the primary language used in the home regardless

of the language spoken by the student?

_______________________________________

What is the language that the student first acquired?

_______________________________________

Preferred correspondence language?

_______________________________________

new address
House Number _____________ Street Direction (N,S,E,W) ___

City

Physical Address

Street Name

________________________________

Street Type (St, Ave, Dr, Pl)

_______

Apt No.

___________

__________________________

County

_________________

Home Phone

Zip Code

State

______

____________

________________________________

Revised 2/04/15

STUDENT NAME______________________________________

Amphitheater Public Schools Student Registration

STUDENT INFORMATION
Part 2 of 4

Preferred Mailing Address

House Number
Street Name

GRADE _________

(if different)

_____________ Street Direction (N,S,E,W) ___

________________________________

Street Type (St, Ave, Dr, Pl)

_______

Apt No.

___________

Transportation

________________________________

City _________________________ State ______

County ______________ Zip Code ____________
Was Your Student in a Special Program?
Special Education Y N
Speech
YN
English Language Learning

Open Enrollment Student

Bus

PO Box

Walk

Gifted Y N
504 Y N
YN

Parent Pick-up

Day Care ____________________________

Last School Attended ________________________

Other _______________________________

Last District Attended ________________________

Other _______________________________

City _________________________ State ______

Other Children Under 18 Living at This Address

Name ____________________ Date of Birth ________

School Attending

_____________________________

Name ____________________ Date of Birth ________

School Attending

_____________________________

Name ____________________ Date of Birth ________

School Attending

_____________________________

Name ____________________ Date of Birth ________

School Attending

_____________________________

Name ____________________ Date of Birth ________

School Attending

_____________________________

Name ____________________ Date of Birth ________

School Attending

_____________________________

I VERIFY ALL OF THE INFORMATION

ON THIS FORM IS ACCURATE

_______________________________________
Enrolling Parent/Guardian Printed Name

_______________________________________
Enrolling Parent/Guardian Signature

Date

Revised2/04/2015

STUDENT NAME______________________________________

Amphitheater Public Schools Student Registration

STUDENT INFORMATION
Part 3 of 4

GRADE _________

Contact # 1 is the students:

Father

Mother

Guardian

Other ______________________

Last Name

_________________________________

Middle Name
Employer

Foster Father

________________________________

__________________________________

Work Phone

____________ Home Phone ____________

Contact electronically

Contact Email

Foster Mother

First Name

Step-Mother

______________________________

Street Address
City

Step-Father

____________________________

_____________________

Cell Phone

Zip Code

_______

____________ Home Language ________

_________________ @ __________________

This contact:
Is primary contact

Lives with student

This contact is RESTRICTED

CAN pick up student

No contact with student

HAS parent portal access

Emergency contact

Receives report card

Restraining Order against

Father

Other _______________________________

Mother

Contact # 2 is the students:

Father

Mother

Guardian

Other ______________________

Last Name

_________________________________

Middle Name
Employer

Foster Father

________________________________

__________________________________

Work Phone

____________ Home Phone ____________

Contact electronically

Contact Email

Foster Mother

First Name

Step-Mother

______________________________

Street Address
City

Step-Father

____________________________

_____________________

Cell Phone

Zip Code

_______

____________ Home Language __________

_________________ @ __________________

This contact:
Is primary contact

Lives with student

This contact is RESTRICTED

CAN pick up student

No contact with student

HAS parent portal access

Emergency contact

Receives report card

Restraining Order against

Father

Mother

Other _______________________________

Revised2/04/2015

STUDENT NAME______________________________________

Amphitheater Public Schools Student Registration

STUDENT INFORMATION
Part 4 of 4

GRADE _________

Contact # 3 is the students:

Father

Mother

Guardian

Other ______________________

Last Name

_________________________________

Middle Name
Employer

Foster Father

________________________________

__________________________________

Work Phone

____________ Home Phone ____________

Contact electronically

Contact Email

Foster Mother

First Name

Step-Mother

______________________________

Street Address
City

Step-Father

____________________________

_____________________

Cell Phone

Zip Code

_______

____________ Home Language ________

_________________ @ __________________

This contact:
Is primary contact

Lives with student

This contact is RESTRICTED

CAN pick up student

No contact with student

HAS parent portal access

Emergency contact

Receives report card

Restraining Order against

Father

Other _______________________________

Mother

Contact # 4 is the students:

Father

Mother

Guardian

Other ______________________

Last Name

_________________________________

Middle Name
Employer

Foster Father

________________________________

__________________________________

Work Phone

____________ Home Phone ____________

Contact electronically

Contact Email

Foster Mother

First Name

Step-Mother

______________________________

Street Address
City

Step-Father

____________________________

_____________________

Cell Phone

Zip Code

_______

____________ Home Language __________

_________________ @ __________________

This contact:
Is primary contact

Lives with student

This contact is RESTRICTED

CAN pick up student

No contact with student

HAS parent portal access

Emergency contact

Receives report card

Restraining Order against

Father

Mother

Other _______________________________

Revised2/04/2015

AMPHITHEATER SCHOOL DISTRICT

PLEASE PRINT

HEALTH INFORMATION CARD

PAINTED SKY ELEMENTARY

FullLegruNameofSrudent,_________________________________________________________ Sex___ Grade___ ____ Painted Sky Elementary ____

(Last)

(Middle)

(Fi"l)

(M/F)

ResidentAddress________________________________________________________________________________________________________
Mailing Address (if different) ______________________________________________________________________________________________
Date of Birth _ _ _ _ __

Place of Birth_______________________________________________________________________________
StaLe

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 office should be aware of? If yes, describe: ______________________________________________
Language(s) spoken by Srudent _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____
Revised 5/08

Language(s) spoken at home ___________________________________

(PLEASE COMPLETE REVERSE SIDE)

Stock Form #W90n

PLEASE CHECK THE FOLLOWING ITEMS, IF THEY PERTAIN TO YOUR STUDENT:

o ADHD

Allergies/drug

Allergies/food

Allergies/seasonal

Asthma

Birth defects

Blood disorder

Bowel/bladder

o Diabetes 0 Glasses/contacts 0 Headaches/migraines 0 Hearing problem 0 Heart condition 0 Orthopedic

o Psychiatric disorder 0 Seizure disorder 0 Other any items were checked, please explain) _________________________________________
(If

If your student is to take medication at school. a signed consent form is required,

Please list g]l 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:

None

AHCCCS

Kids Care

Indian Health Services

Other Health Plan _ _ _ _ _ _ _ _ _ _ _ ___

Doctor _______________________________________ Phone _____________________ Hospital Preference _____________________________

If parenUguardian 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 office 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 officials. 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 __________________________
(Signarure verifies that all of the information on this card is accurate.)

ADMISSION OF RESIDENT STUDENTS

RESIDENCY DOCUMENTATION FORM
Amphitheater Unified School District
Student _________________________________________ _

Painted Sky Elementary

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, Valid U.S. passport or motor vehicle
registration
__ 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
__

1st _ 5th GRADE STUDENT QUESTIONNAIRE

(this form will be provided to next year's teacher)*
Child's Name: - - -

Nickname:

ParentlGuardian(s) name: _ _ __
With whom is the child living?

Has there been a divorce, death or illness in the family which might affect your child? _ _ _ _ _ __

Social Experiences:

Would you say your child is a leader or a follower? (Please circle one)

How much television does your child watch daily? _ _ _---'hrs

Does your child enjoy books? _ _

Do you read to/with your child? _ _ _ _ _ How often?

What are your child's favorite activities? _ _ _ _ _ _ _ _ _ _ _~_ _ _ _ _ _ _ _ _ __

Development:
\Vhat name do you want your child to write on hislher work? _ _ _ _ _ _ _ _ _ _ _ _ _ __
Is your child aware of dangers such as fire, electricity, traffic and strangers? ___
Does your child know your phone number? _ _ _ __
Does your child know your address? ._ _ _ __
What kind of difficulties do you have most with your child? .._ _ __

\Vhat would you say are your child's strengths?

What would you say are your child's weaknesses?

What are the things you want your child to get most out of school?

*This form is Itot used (or class placement. It will be given to the teacher wlw your child is assigned to
for "ext year, This will help their new teacher learn more about their incoming students.
4/8/2011

CELL PHONE USAGE AGREEMENT

I understand that Painted Sky Elementary School and their

representatives are not responsible for the loss, theft or damage of
personal cell phones that are brought to school. Cell phones are for
emergency purposes only, before and after school. Cell phones will be
confiscated if they are used or ring at any other time throughout the
school day. Confiscated phones must be picked up by a parent or
guardian
If a student wishes to call their parent/guardian from the bus line or
school bus they must first have permission from the staff member on duty.

Student Name
Grade
My child will
at school.

will not

C h i l d s c e l l p h o n e nu m b e r
Pa r e n t / G u a r d i a n
Date
Te a c h e r

be car r ying a cell phone