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1 New Student Enrollment Checklist Parent Interview with the Director Child s Interview with the Director and Lead Teacher School Tour Completed New Student Enrollment Application Completed Emergency Information & Immunization Record form (EIIR) Completed Medication Consent form, if applicable Copy of child s immunization records Copy of child s birth certificate Signed Tuition & Payment Agreement, if applicable (first payment due by July 1 st ) Additional documents required for Kindergarten-Elementary students only: Completed Free & Reduced Lunch Eligibility form (FRL) Completed Primary Home Language Form (PHLOTE) Completed Arizona Residency Documentation Form & copy of supporting document Completed Student Records Request form Completed Student History form Completed ECA Tax Credit form (optional) Please be sure that all required forms have been filled out completely before submitting. FOR OFFICE USE ONLY Student Name: Program/Level: Date Received: _ Received by: _ Revised: 02/05/2015

2 Ne w Student Enrollment Application IMPORTANT: Completed New Student Enrollment Packets will be considered on a first come, first served basis. If the selected program level is full, your child will be placed on the Wait List. Completed packets will be kept on file for the entire school year and you will be notified immediately if an opening becomes available. FOR OFFICE USE ONLY EIIR Birth Certificate Proof of Residency FRL Eligibility PHLOTE Custody Papers (if applicable) Tuition Fees (if applicable) Parent Handbook SAIS ENTRY DATE: SAIS # Child s Name (PLEASE PRINT): Last Name First Name MI PROGRAM LEVEL: ½ Day AM Preschool Full Day Preschool ½ AM Day Kinder Full Day Kinder 1 st Grade 2 nd Grade 3 rd Grade NOTE: The child must be five years old by 09/01/15 to apply for Kindergarten, and six years old by 09/01/15 to apply for 1st grade. BACKGROUND INFORMATION Child s date of birth: Gender: Male Female (MM/DD/YYYY) School/Preschool currently attending/most recently attended: Does the child have previous Montessori experience? Yes No If yes, Montessori School: _Years attended: Has child ever been suspended or expelled from any school? Yes No If yes, please provide date(s) & explain: _ CHILD S ETHNICITY & LANGUAGE (This information is required by the Arizona Department of Education) Is child Hispanic/Latino? YES NO ETHNICITY: WHITE BLACK/AFRO-AMERICAN ASIAN AMERICAN INDIAN/NATIVE ALASKAN NATIVE HAWAIIAN/PACIFIC ISLANDER Language most often spoken in the home? English Other: Language most often spoken by the child? English Other: Please identify the child s first spoken language: English Other: PARENT INFORMATION (PLEASE PRINT) Parent/Guardian #1: _ Physical Address: _ City/State/Zip: Mailing Address: City/State/Zip: Home Phone: Work Phone: _ Cell Phone: Parent/Guardian #2: _ Physical Address: _ City/State/Zip: Mailing Address: City/State/Zip: Home Phone: Work Phone: _ Cell Phone:

3 SPECIAL NEEDS Has your child ever been assessed and/or evaluated for special needs or learning differences? Yes No If yes, please identify & explain: Does your child have a current IEP (Individual Education Plan)? Yes No A current 504 plan? Yes No Why have you chosen a Montessori education for your child? What are your educational goals for your child? ADDITIONAL PROGRAM INTEREST SURVEY Would you be interested in enrolling your child for any of the following programs, if offered? Extended Day Care? Yes No Holiday Care (Fall, Winter, Spring Breaks)? Yes No 2015 Summer School Program for June? Yes No July? Yes No How did you hear about Camino Montessori? School Website InMaricopa Magazine/Newspaper A friend or family member The Maricopa Monitor Newspaper Facebook Other (Please specify): _ PROMOTIONAL MATERIALS: The undersigned hereby gives consent to Camino Montessori to use photographs, video, and/or movies taken of this enrolled child for promotional use. Parent/Guardian #1 Signature Date Parent/Guardian #2 Signature Date PARENT/GUARDIAN SIGNATURE(S) I/WE understand that the Student Enrollment Packet will be considered on a first-come, first-served basis and, furthermore, that our child s enrollment is also contingent upon available space at the appropriate level. I/we further understand that the Montessori curriculum is presented as a 3-4 year cycle for Elementary I (1 st -3 rd grade & 4 th -6 th grade) and that completing the full program s cycle will provide the optimal educational benefit to my/our child. Parent/Guardian #1 Signature Date Parent/Guardian #2 Signature Date Revised: 02/05/2015

4 Camino Montessori EIN #: Tax Credit Information SUPPORT OUR STUDENTS Camino Montessori offers parents and the members of the broader community numerous ways to get involved. We encourage parents to interact with the school and their student s teachers by attending school events and assisting with the planning and execution of school activities. Through this support, parents and community members can help enhance special learning and creative activities for our school s students, as well as assist in the purchase of supplies, equipment, insurance and related costs and expenses for these activities. Arizona tax law (ARS ) allows taxpayers a tax credit of up to $200 (or $400 per marr ied couple) if they contribute to character education programs or extracurricular activities in publicly funded schools by December 31. As a state funded charter school, Camino Montessori qualifies for this credit. WHAT IS A TAX CREDIT? A tax credit will allow you to reduce the amount of your tax liability to the state. The amount you donate (up to $200 for si ngle taxpayers or $400 for married couples filing jointly) will be the amount you may claim as a state tax credit. For example, if you donate $200, your state tax credit will be $200. When you file your state tax return, your state tax liability will be $200 less. This means that every dollar gifted is taken directly off of your income tax bill or refunded back to you if you do not owe additional taxes. By donating, you are sending tax dollars directly to the school(s) of your choice instead of the Arizona Department of Revenue. You may also deduct your tax-deductable donation on your federal tax return, thus, reducing your federal taxes, as well. ELIGIBILITY All individual Arizona taxpayers qualify to donate and receive a tax credit in the amount of their donation (up to $200 for single taxpayers or $400 for married couples filing jointly). You do not have to have a child enrolled in school for your donation to be eligible for the state tax credit. All donations must be received by December 31 to be claimed on the current year s tax return. You will be provided a receipt as a confirmation of your donation. When you file your AZ tax return, be sure to claim your tax credit. ACTIVITES YOU CAN SUPPORT GENERAL ACTIVITY FUND Educational Field Trips Science Materials and Equipment Physical Education Materials and Equipment Music & Art Activities, Materials, and Equipment School Garden, Composting, and Recycling Program Language Arts HOW TO DONATE a. Complete the attached form b. Mail or deliver the form along with your donation (cash, check or money order) to: Camino Montessori W Maricopa/Casa Grande Hwy Maricopa, AZ PHONE

5 Camino Montessori EIN #: Camino Montessori State Tax Credit Donation DATE: NAME(S): _ ADDRESS: CITY: _ STATE: ZIP CODE: PHONE NUMBER: DONATION AMOUNT $ Please check the category you would like your donation to support: GENERAL ACTIVITY FUND to be used for general support of all applicable programs. Educational Field Trips Science Materials and Equipment Physical Education Materials and Equipment Music & Arts & Crafts Activities, Materials, and Equipment Music Language Arts Please submit your completed donation form and check, money order, or cash amount to the front office or mail it to: Camino Montessori W Maricopa/Casa Grande Hwy Maricopa, AZ Learn more about tax credit benefits at: Credits/School TaxCredits for Individuals.aspx The Arizona Education Tax Credit can be claimed on personal returns only. Contributions from businesses are also welcome. Such contributions are deductible, but cannot be used to claim a tax credit Camino Montessori

6 CDC/SGH# or name: Arizona Department of Health Services Bureau of Child Care Licensing Emergency, Information and Immunization Record Card Child s Name: Date Enrolled: Updated: Home Address (#, Street, City, State, Zip Code): Date Disenrolled: Home Phone: Date of Birth: Sex: male female Mother or Guardian Name: Home Address (#, Street, City, State, Zip Code): Cell Phone (optional): Contact Telephone Number: Father or Guardian Name: Home Address (#, Street, City, State, Zip Code): Cell Phone (optional): Contact Telephone Number: I authorize the following individuals to collect my child from the facility in case of emergency or if I cannot be contacted: (Pursuant to R B, at least two contact persons are required.) Name: Contact Telephone Number: Name: Contact Telephone Number: Name: Contact Telephone Number: Name: Contact Telephone Number: If Medical care is necessary, call: Health Care Name: Contact Telephone Number: Provider* *A Health Care Provider is a physician, physician assistant or registered nurse practitioner. In case of injury or sudden illness, I request that this individual be called first: The following individual(s) may NOT remove my child from the facility: Name(s): Custody papers have been provided and are on file at the facility. yes no Telephone Authorization Code (optional): _

7 Immunization Information (A licensee shall attach an enrolled child's written immunization record or exemption affidavit to the enrolled child's Emergency, Information and Immunization Record card.) For information regarding current immunization requirements go to: or contact the Arizona Immunization Program Office at (602) One of these items must accompany the EIIR card at all times: Copy of current official documented immunization record attached Religious Beliefs exemption form signed by parent/guardian attached Medical Exemption form signed by physician and parent/guardian attached Signed Laboratory Proof of Immunity form attached Notification of immunizations needed sent to Parent(s) or Guardian(s): Updated immunizations received and attached: mo /day/ yr mo /day/ yr mo /day /yr mo /day/ yr mo /day/ yr mo /day /yr Medical Information Is child allergic to food or other substances? No Yes If yes, describe symptoms, name foods or substances to be avoided, and the procedure to follow if reaction occurs: Is child usually susceptible to infections and if so, what precautions need to be taken? No Yes If yes, list precautions: Is child subject to convulsions and what should be our procedure if one occurs? No Yes If yes, specify procedure: Is there any physical condition that we should be aware of and what precautions should be taken (heart trouble, foot problem, hearing impairment, hernia, etc.)? If yes, list precautions: No Yes Additional comments: Other special instructions: This Emergency Information and Immunization Record Card is accurate and complete, front and back, and was provided by: Parent/Guardian PRINTED Name: SIGNED Name: DATE: G:\Forms\Emergency Information and Immunization Record Card (9/11) (4/14)

8 Helping All Children Succeed Do you have concerns about your child s development or progress in school? What Is Child Find? Child find is a component of the Individuals with Disabilities Education Act (IDEA '04) that requires states to locate, identify, and evaluate all children with disabilities, aged birth through 21, who are in need of early intervention or special education services. This includes children who are highly mobile, such as migrant or homeless children, children suspected of having a disability even though they are advancing from grade to grade, private school students, and homeschool students. The Arizona initiative for child find is referred to as AZ FIND. Children Develop at Different Rates Some children have more difficulty learning than others. They may have trouble achieving milestones in one or more of the following developmental or academic areas: Vision and Hearing Speech or Communication Skills Motor Control or Coordination Cognitive or Academic Skills Behavior or Social Skills The earlier you express your concerns, the sooner your child s needs will be identified and the sooner he or she will receive the help needed to succeed. Anyone can refer a child, birth through age 21, for early intervention or special education services. The referral can come from a parent, foster parent, teacher, counselor, friend, relative, or the student who finds learning difficult. Screening and evaluation services are free. If You Have Concerns If you have concerns about your child s development or progress in school, contact the Arizona Early Intervention Program (AzEIP) or your local school. AzEIP screens children ages birth to 2 years 10 1/2 months to determine if early intervention services are needed. An AzEIP specialist will come to your home to talk with you about your concerns and observe your child. If your child is found eligible, a plan will be designed to include strategies, activities, and supports to achieve desired outcomes related to your child s development. For concerns regarding your child ages 2 years 10 1/2 months through 21 years, contact your local school district or the charter school your child attends. Public schools use a screening process to check your child s development and academic progress. If an evaluation is needed, you will be a part of the evaluation team. You will be involved in the decision-making process to determine if your child is eligible for special education and related services. Eligible students are entitled to a free and appropriate public education (FAPE). Who Can Help? For children ages birth to 2 years 10 1/2 months, contact AzEIP at: or call or (602) For children ages 2 years 10 1/2 months through 21 years, contact your local school district or the charter school that your child attends. For children attending private schools, contact your principal for a referral to the appropriate public education agency. Information Is Confidential All information contained in the screening or evaluation is confidential. Parent Involvement Parent involvement in the special education process is critical to your child s success. You are the best advocate for your child. Ask the school for a copy of the Procedural Safeguards Notice. This will explain your special education rights. Don t be afraid to ask questions. Find out what tests will be given to your child and why they have been considered. Be involved in your child s evaluation. Find out what kind of information you will be asked to contribute to the process. Request copies of important paperwork, including a copy of the final report. Maintain those documents in a safe place. Keep a log of phone calls. Use your calendar to track testing dates and meetings. Contact the Parent Information Network (PIN) for FREE special education resources, consultation, and training. Visit the PIN website to locate the PIN Specialist in your area, or call PINS (7467). Every school district and charter school is assigned an Education Program Specialist through the Arizona Department of Education, Exceptional Student Services. To contact an Education Program Specialist call: Phoenix (602) , Tucson (520) , or Flagstaff (928)

9 Ayudando a Que Todos Los Niños Tengan Exito Le preocupa el desarollo de su niño o su progreso en la escuela? Qué Es Child Find? Child Find es un componente de la Ley de Educación de Individuos con Discapacidades 2004 (IDEA 04 por sus siglas en inglés), que requiere que los estados localizen, identifiquen, y evalúen todo niño con discapacidades, desde recién nacido hasta la edad de 21 años, que necesitan intervención temprana o servicios de educación especial. Esto incluye a niños que son móviles, tal como niños migrantes o sin hogar, niños quienes se sospecha tener discapacidades aunque están avanzando de grado a grado, estudiantes en escuelas privadas, y estudiantes educados en sus hogares. La iniciativa de Arizona para child find es AZ FIND. Los Niños se Desarrollan a Diferentes Niveles Algunos niños tienen más dificultad en el aprender que otros. Pueden tener dificultad en alcanzar hitos en una o más de las siguientes áreas de desarrollo o académicas: Visión o el Oir Control Motor o Coordinación Comportamiento o Destrezas Sociales Lenguaje o Destrezas de Comunicación Cognitivo o Destrezas Académicas Cuanto más temprano usted exprese sus preocupaciones, lo más pronto que las necesidades de su niño seran identificadas, y lo más pronto que él o ella recibirá la ayuda necesaria para tener éxito. Cualquier persona puede referir a un niño, desde recien nacido hasta la edad de 21 años, para servicios de intervención temprana o educación especial. El referido puede llegar de un padre, padre de acogida, maestro, consejero, amigo, pariente, o el estudiante que se le hace dificil el aprendizaje. Servicios de evaluación son gratuitos. Si Tiene Preocupaciones Si le preocupa el desarrollo de su niño o su progreso en la escuela, comuníquese con el Programa de Intervención Temprana de Arizona (AzEIP), o su escuela local. AzEIP evalua los niños desde recien nacidos hasta 2 años 10 1/2 meses, para determiner si los servicios de intervención temprana son necesarios. Un especialista de AzEIP vendrá a su hogar para hablar con usted acerca sus preocupaciones y para observer a su niño. Si su niño es elegible, se diseñará un plan que incluirá estrategias, actividades, y apoyos para alcanzar las metas deseadas para el desarrollo de su niño. Para preocupaciones con relación a su niño de las edades de 2 años 10 meses hasta 21 años, comuníquese con el distrito escolar local o escuela charter donde atiende su niño. Las escuelas públicas usan un proceso de investigación para comprobar el desarrollo de su niño y progreso académico. Si se necesita una evaluación usted será parte del equipo de evaluación. Usted tomará parte en el proceso de decisiones para determiner si su niño es elegible para servicios de educación especial y servicios relacionados. Estudiantes que son elegibles tienen el derecho a una educación pública gratuita y apropiada (FAPE). Quien Puede Ayudar? Para niños recien nacidos hasta la edad de 2 años 10 1/2 meses, comuníquese con AzEIP a: o llame al o al Para niños de las edades de 2 años-10 1/2 meses hasta los 21 años, comuníquese con su distrito escolar local o con la escuela charter donde atiende su niño. Para niños que asisten a escuelas privadas, comuníquese con su principal para un referido a la agencia educativa apropiada. La Información es Confidencial Toda información contenida en la evaluación es confidencial. La Participación de Los Padres La participación de los padres en el proceso de educación especial es importante para los logros de su niño. Usted es el mejor defensor para su niño. Pídale a la escuela una copia de la Notificación de Garantías Procesales. Ésto explica sus derechos para la educación especial.

10 No tenga miedo de hacer preguntas. Averigue qué pruebas se le daran a su niño y porqué se han considerado. Participe en la evaluación de su niño. Averigue qué tipo de información se le pedirá para el proceso. Pida copias de documentos importantes, incluyendo una copia del reporte final de evaluación. Mantenga esos documentos en un lugar seguro. Mantenga un registro de llamadas telefónicas. Utilice su calendario para seguir las fechas de pruebas y reuniones. Comuníquese con la Red de Información para Padres (PIN, por sus siglas en inglés) para recursos GRATUITOS de educación especial, consultas, y entrenamientos. Visite la página de web de PIN para localizer la Especialista de PIN en su area, o llame al PINS (7467). Cada distrito escolar y escuela charter se le asigna una Especilista de Programas de Educación, Servicios de Estudiantes Exepcionales. Para comunicarse con una Especialista de Programas de Educación llame a: Phoenix, (602) ; Tucson, (520) , o Flagstaff, (928)

11 Guidelines to Determine Eligible Students The Arizona Department of Education provides the following FY 2016 Income Guidelines for determining eligibility information for federal funding associated with programs funded under the Elementary and Secondary Education Act, ESEA. Is your family at or below the current income guidelines based on the attached ESEA Eligibility Guidelines schedule? Indicator 1 Indicator 2 NO Definition of Income: All items such as wages and salaries before any deductions, and other income, such as self employment, welfare, social security, retirement benefits unemployment compensation, workers compensation, Aid for Dependent Children, alimony, child support, pensions, insurance or annuity payments, etc. If your family qualifies, please complete the following information for each child: Child s Name Name of School Grade I hereby certify that all of the above information is true and correct. Parent Signature: Date: NOTE: These survey forms should be retained by the school or district and kept on file for a period of 5 years. Arizona Department of Education Income Eligibility effective July 1, 2015 to June 30, 2016 ADE update as of April 1, 2015

12 ESEA Eligibility Guidelines Effective from July 1, 2015 to June 30, 2016 Indicator I Free Indicator 2 Reduced Household Size Yearly Monthly Twice per month Every 2 weeks Weekly Yearly Monthly Twice per month Every 2 weeks Weekly 1 $15,301 $1,276 $638 $589 $295 $21,775 $1,815 $908 $838 $419 2 $20,709 $1,726 $863 $797 $399 $29,471 $2,456 $1,228 $1,134 $567 3 $26,117 $2,177 $1,089 $1,005 $503 $37,167 $3,098 $1,549 $1,430 $715 4 $31,525 $2,628 $1,314 $1,213 $607 $44,863 $3,739 $1,870 $1,726 $863 5 $36,933 $3,078 $1,539 $1,421 $711 $52,559 $4,380 $2,190 $2,022 $1,011 6 $42,341 $3,529 $1,765 $1,629 $815 $60,255 $5,022 $2,511 $2,318 $1,159 7 $47,749 $3,980 $1,990 $1,837 $919 $67,951 $5,663 $2,832 $2,614 $1,307 8 $53,157 $4,430 $2,215 $2,045 $1,023 $75,647 $6,304 $3,152 $2,910 $1,455 For each additional household member, add: $5,408 $451 $226 $208 $104 $7,696 $642 $321 $296 $148 Arizona Department of Education Income Eligibility effective July 1, 2015 to June 30, 2016 ADE update as of April 1, 2015

13 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, R (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 West Jefferson Street, Phoenix, Arizona

14 Estado de Arizona Departamento de Educación Servicios de Aprendizaje del Inglés Idioma Principal en el Hogar excluyendo el inglés (PHLOTE) Encuesta sobre el Idioma en el Hogar (Efectivo el 4 de abril de 2011) Preguntas en conformidad con R (B)(1), (2)(a-c) del Reglamento de la Junta Directiva. Las respuestas que proporcione a las preguntas siguientes serán usadas para determinar si se evaluará la competencia en el idioma inglés de su hijo(a). 1. Cuál idioma se habla principalmente en su hogar sin considerar el idioma que habla el estudiante? _ 2. Cuál idioma habla el estudiante con mayor frecuencia? 3. Cuál fue el primer idioma que aprendió el estudiante? Nombre del estudiante Núm. de identificación _ Fecha de nacimiento Núm. de SAIS _ Firma del padre o tutor Fecha Distrito o Charter Escuela 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 West Jefferson Street, Phoenix, Arizona

15 Arizona Department of Education Arizona Residency Guidelines 9/22/11 INTRODUCTION Generally, under Arizona law, only Arizona residents are entitled to a free public education. The Arizona Department of Education ( Department ) is a designated steward of state education tax dollars and is responsible for providing state aid to school districts and charter schools for students who reside in Arizona. Pursuant to A.R.S (J), a school district or charter school may not include non-resident pupils in their student count and may not obtain state aid for those pupils. The residency of a student is determined by the residency of the parent or guardian with whom the student lives. Accordingly, it is the responsibility of the school districts and charter schools that receive state aid to ensure that their student/parent residency information is accurate and verifiable. The Department may audit schools to ensure that only Arizona resident students are reported for state aid. Any school district or charter school that cannot demonstrate the accuracy of any student s residency status may be required to repay the state aid received for that student. VERIFIABLE DOCUMENTATION A.R.S (B) requires school districts and charter schools to obtain and maintain verifiable documentation of Arizona residency upon enrollment in an Arizona public school. This document is designed to assist school districts and charter schools in meeting the legal requirements of the statute. The documentation required by A.R.S must be provided each time a student enrolls in a school district or charter school in this state, and reaffirmed during the district or charter s annual registration process via the district or charter s annual registration form. The documentation supporting Arizona residency should be maintained according to the school s records retention schedule. In general, students will fall into one of two groups: (1) those whose parent or legal guardian is able to provide documentation bearing his or her name and address; and (2) those whose parent/legal guardian cannot document his or her own residence because of extenuating circumstances including, but not limited to, that the family s household is multi-generational. Different documentation is required for each circumstance. 1. Parent(s) or legal guardian(s) that maintains his or her own residence: The parent or legal guardian must complete and sign a form indicating his or her name, the name of the school district, school site, or charter school in which the student is being enrolled, and provide one of the following documents, which bear the parent or legal guardian s full name and residential address or physical description of the property where the student resides (no P.O. Boxes): Valid Arizona driver s license, Arizona identification card Valid Arizona motor vehicle registration Valid United States passport Property deed #

16 Mortgage documents Property tax bill Rental agreement or lease (including Section 8 agreement) Utility bill (water, electric, gas, cable, phone) Bank or credit card statement W-2 wage statement Payroll stub Certificate of tribal enrollment or other identification issued by a recognized Indian tribe Other documentation from a state, tribal, or federal agency (Social Security Administration, Veterans Administration, Arizona Department of Economic Security, etc.) 2. Parent(s) or legal guardian(s) that does not maintain his or her own residence: The parent or legal guardian must complete and sign a form indicating his or her name, the name of the school district, school site, or charter school in which the student is being enrolled, and submit a signed, notarized affidavit bearing the name and address of the person who maintains the residence where the student lives attesting to the fact that the student resides at that address, along with a document from the bulleted list above bearing the name and address of the person who maintains the residence. A model affidavit is available for schools at: USE OF AND RETENTION OF DOCUMENTS BY SCHOOLS School officials must retain a copy of the attestations or affidavits and copies of any supporting documentation presented for each student (photocopies acceptable) that school officials believe establish validity. Documents presented may be different in each circumstance, and unique to the living situation of the student. Documents retained by the school district or charter school may be used as an indicia of residency; however, documentation is subject to audit by the Department. Personally identifiable information other than name and address (SSN, account numbers, etc.) should be redacted from the documentation either by the parent/guardian or the school official prior to filing. #

17 Arizona Department of Education Arizona Residency Documentation Form 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 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 #

18 State of Arizona 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: 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 The foregoing was acknowledged before me this _ day of, 20_, By. _ Notary Public My Commission Expires: #

19 Departamento de Educación de Arizona Formulario de Documentación de Residencia en Arizona Nombre del Estudiante Nombre de Escuela Distrito Escolar o Escuela Chárter Padre/Tutor Legal Como el padre del estudiante o represéntate legal, doy fe de que soy residente del estado de Arizona y presento como prueba de esta declaración copia del siguiente documento que muestra mi nombre y la dirección residencial o la descripción física de la propiedad donde reside el estudiante: Licencia de conducir valida del Estado de Arizona, tarjeta de identificación de Arizona o registro de vehículo Pasaporte válido de los EE. UU. Escritura inmobiliaria o documentos de hipoteca Recibo de pago de impuestos sobre la propiedad Contrato de renta de casa/residencia Factura de cuenta sobre el uso de agua, electricidad, gas. Cable de TV, o teléfono Factura de tarjeta de crédito o de banco Copia de la forma W-2 sobre declaración de ingresos Talón del cheque de paga Certificado de inscripción u otra identificación emitida por una tribu indígena reconocida que contiene una dirección de Arizona. Documentación de una agencia estatal, gobierno federal (Administración de Seguro Social, Administración de Veteranos, Departamento de Seguridad Económica de Arizona) o agencia gubernamental de alguna tribu nativa Norte Americana. Actualmente no puedo proporcionar ninguno de los documentos mencionados. Por lo tanto, he proveído una declaración original, firmada y notariada por un residente de Arizona que da fe de que he establecido residencia en Arizona con la persona que firma esta declaración. _ Firma del padre/tutor legal _ Fecha #

20 Estado de Arizona Declaración Jurada de Residencia Compartida Juro o afirmo soy un residente del Estado de Arizona y que las siguientes personas viven conmigo en mi residencia, se describe de las siguiente manera: Las personas que viven con migo: Ubicación de me residencia: Yo presento en apoyo de esta declaración una copia del siguiente documento que muestra mi nombre y dirección de residencia actual o descripción física de mi propiedad. Licencia de conducir valida del Estado de Arizona, tarjeta de identificación de Arizona o registro de vehículo Pasaporte válido de los EE. UU. Escritura inmobiliaria o documentos de hipoteca Recibo de pago de impuestos sobre la propiedad Contrato de renta de casa/residencia Factura de cuenta sobre el uso de agua, electricidad, gas. Cable de TV, o teléfono Factura de tarjeta de crédito o de banco Copia de la forma W-2 sobre declaración de ingresos Talón del cheque de paga Certificado de inscripción u otra identificación emitida por una tribu indígena reconocida que contiene una dirección de Arizona. Documentación de una agencia estatal, gobierno federal (Administración de Seguro Social, Administración de Veteranos, Departamento de Seguridad Económica de Arizona) o agencia gubernamental de alguna tribu nativa Norte Americana. Actualmente no puedo proporcionar ninguno de los documentos mencionados. Por lo tanto, he proveído una declaración original, firmada y notariada por un residente de Arizona que da fe de que he establecido residencia en Arizona con la persona que firma esta declaración. #

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