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Cherry Street, Cottonwood, AZ 86326 Entry Code____________ Phone 928-634-2144 Fax 928-634-9053 Entry Date____________ STUDENT ENROLLMENT FORM Student #_____________ 2010 - 2011 School Year SAIS # ______________ ____This student is a sibling of a currently enrolled student This year I will be in Grade ________ ALL QUESTIONS MUST BE ANSWERED NOTE: If your student has been expelled within the last 18 months, enrollment is prohibited by Board Policy. STUDENTS NAME _________________________________________________________________________________________________ Legal Last First Full Middle Nickname “ Gender ____ Birth Date ____________________________________ Age ______ Birthplace _____________________________________ Month Day Year City and State Social Security # ______________________________________________ (Not mandatory) Location Address ___________________________________________________________________________________________________ Number & Street Apt. or Space # City Zip Mail Address ___________________________________________________________________________________________________ Number & Street Apt. or Space # City Zip Phone Number Home_____________________ Work__________________ Cellular __________________ E-Mail _______________ ___ MEDICAL ALERT or special health condition _______________________________________________________________________ EMERGENCY phone number other than immediate family _ __________________Emergency contact person _____________________________________ Name of contact & Relationship Students Physician ________________________________________________ Phone Number ___________________________________ Parent/Guardian Names: (Guardian, step parents, foster parents: copies of court appointment or divorcee decree must be attached) Father: ____________________________________________________________________________________________________________ Last Name First Name Initial Employed By Phone ____ Biological Father ____ Step-Father ____ Grandfather ____ Other, Specify __________________________________________ Mother: ___________________________________________________________________________________________________________ Last Name First Name Initial Employed By Phone ____ Biological Mother ____ Step-Mother ____ Grandmother ____ Other, Specify __________________________________________ Student lives with: ____Parents ____Mother ____Father ____Other, Specify _______________________________________________ Who Address/Phone Who has legal custody? ____ Parents ____Mother ____Father ____Grandparents ____Other, Specify _________________________ HOME LANGUAGE SURVEY: (AZ State mandated) What is the primary language of the student? ______________________________________________________ ETHNIC/RACIAL BACKGROUND: (AZ State mandated) ___White ___Black ___Hispanic ___ American Indian ___Asian ___Other _______ Specify School Last Attended: ___________________________________________________________________________________________________________ Name of School Mailing Address Has your child ever been in a Special Education program? ____ Yes ____ No (The answer to this question will not effect enrollment). Current I.E.P. _____Yes _____ No Label __________________ Last I.E.P. Review ____________________ (Attach a copy of most recent I.E.P). ________I have received the “Notification to Parents Regarding Confidentiality of Student Records and School Educational Records” (F.E.R.P.A.) And a (initial) “Summary of Special Education Services,” also contained in the Student Handbook, and IDEA Disabilities Act Notification Please attach copies of, ___Most recent grades/transcript ___Birth Certificate ___ AIMS test or equivalent ___Immunization form SIGNATURE OF PARENT OR LEGAL GUARDIAN _____________________________________________________ Date _____________ Ke•Ÿ Ж h m І $ I ^ w {  œ­)/™wx††Хж№!"!"2"ж"іюуюлалалалалЧлюуюПЖПлПлПлюПЋПЋПhЉA35CJ\aJhЉA3>*CJaJhЉA3CJaJhЉA3>*CJaJhЉA35CJ\aJhЉA3CJaJhЉA35CJ\aJhЉA3CJaJhЉA3>*CJaJ eЯl Р C i h i   t ' Ё P‘аEїј$%›œ™‡џ§§§§§§§§§§§§§§§§§§§§§§§§§§§§§ж"§‚ƒјІ+џs"ЃyћХIJtuйж`GЩ}~’ “ )!Г!3"4"§§§§§§§§§§§§§§§§§§§§§§§§§§§§§4"5"Є"Ѕ"Ї"Ј"Љ"ж"§§§ї§§§ Ц€50P:pЉA3Аа/ Ар=!Аh"Аh#<$<%АА<А< а†œL@ёџL Normal1$7$8$H$CJ_HaJmH sH tH DA@ђџЁD Default Paragraph FontRiѓџГR  Table Normalі4ж l4жaі (k@єџС(No List <&@ђџё< Footnote Referenceж.џџџџeЯlРCihit'ЁP‘аEїј$ % › œ   ™ ‡ џ ‚ ƒ ј І +џs"ЃyћХIJtuйж`GЩ}~’“)Г345ЄЅЇЈЉиˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ˆ‘0ж"4"ж"ж"џџџџџџџџџЈЈЈЈЈЈЈЈџџчџџхЉA3›.Ћџ@OKI C9600(PS)Ne01:winspoolOKI C9600(PS)OKI C9600(PS)мШSџ€ъ odXXLetterPRIVт0''''шМ \KhC‰иМЏ+џџшSMTJиOKI C9600(PS)DuplexNoneInputSlot*UseFormTrayTablePageSizeLetterPageRegionLeadingEdgeResolution600dpiOKResolutionGRADATIONOKImageSmoothingFalseOKCollateFalseOKEnvRotateFalseOKHairLineTrueOKControlAutoOKAlwaysPrnHTTrueOKOverPrintFalseOKOutputModeFalseOKScreenOboTrueOKSeparationorderOFFOKColorRenderStyleAutoOKTargetColorNoneOKBlackSubstitutionAutoOKColorICMSICCProOKColorMatchFineOKPreserveBlackTrueOKRGBProfilesRGBOKCMYKProfileInputOKCMYKInputProfileNoneOKCMYKLinkProfileNoneOKSimProfileNoneOKOutProfileAutoOKColorRenderDictPerceptualOKBlackSubGraGlossyOKPureBlackTrueOKPageSizeCheckTrueOKMediaTypePRINTERDEFAULTOKManualFeedFalseOutputBinStackerOKBindPositionLeftOKStapleNoneOKPunchNoneTraySwitchTrueOKJob_TypeNormalOKHDDSpoolFalseOKOverlayNotUse 0002џ &ZOKI C9600(PS)мШSџ€ъ odXXLetterPRIVт0''''шМ \KhC‰иМЏ+џџшSMTJиOKI C9600(PS)DuplexNoneInputSlot*UseFormTrayTablePageSizeLetterPageRegionLeadingEdgeResolution600dpiOKResolutionGRADATIONOKImageSmoothingFalseOKCollateFalseOKEnvRotateFalseOKHairLineTrueOKControlAutoOKAlwaysPrnHTTrueOKOverPrintFalseOKOutputModeFalseOKScreenOboTrueOKSeparationorderOFFOKColorRenderStyleAutoOKTargetColorNoneOKBlackSubstitutionAutoOKColorICMSICCProOKColorMatchFineOKPreserveBlackTrueOKRGBProfilesRGBOKCMYKProfileInputOKCMYKInputProfileNoneOKCMYKLinkProfileNoneOKSimProfileNoneOKOutProfileAutoOKColorRenderDictPerceptualOKBlackSubGraGlossyOKPureBlackTrueOKPageSizeCheckTrueOKMediaTypePRINTERDEFAULTOKManualFeedFalseOutputBinStackerOKBindPositionLeftOKStapleNoneOKPunchNoneTraySwitchTrueOKJob_TypeNormalOKHDDSpoolFalseOKOverlayNotUse 0002џ &Z€ш7}ж@@џџUnknownџџџџџџџџџџџџGџ:рAxР џTimes New Roman5€Symbol3& џ:рCxР џArial"ˆ аh›ч&›ч&е 0е 0! €бЅРxxƒЩЩ €бзп№џ?џџџџџџџџџџџџџџџџџџџџџЉA32џџ aha kathy ўџр…ŸђљOhЋ‘+'Гй0h˜ЄАМШдф ј $ 0 <HPX`фNormal aha kathy2Microsoft Office Word@вIk@ќ§Јw'Ы@ЮGx'ЫеўџеЭеœ.“—+,љЎ0ш hp|„Œ” œЄЌД М Щф0 Щ'  Title ўџџџ !"#$%&'()*+,-./0123456ўџџџ89:;<=>ўџџџ@ABCDEFўџџџ§џџџIўџџџўџџџўџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџRoot Entryџџџџџџџџ РFрuж4x'ЫK€1Tableџџџџџџџџ*=WordDocumentџџџџџџџџ7.SummaryInformation(џџџџ7DocumentSummaryInformation8џџџџџџџџџџџџ?CompObjџџџџџџџџџџџџqџџџџџџџџџџџџџџџџџџџџџџџџўџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџўџ џџџџ РFMicrosoft Office Word Document MSWordDocWord.Document.8є9Вq