Riverside Traditional School P.A.W.S Center Preschoolers Acheving the World through Social Skills Enrollment Packet 2015-2016 Required Documents: (These documents should be submitted with the application) o Original Birth Certificate or U.S Passport o Immunization Records o Proof of Income: Public Assistance Letter within last 6 months or 1 Month of consecutive check stubs & 2014 tax records with listed dependents. o Employer Information o Photo I.D. of Parent/Guardian o Proof of Address (Utility Bill or lease agreement with Parent name or notarized letter).
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Riverside Traditional School
P.A.W.S Center Preschoolers Acheving the World through Social Skills
Enrollment Packet
2015-2016
Required Documents:
(These documents should be submitted with the application)
o Original Birth Certificate or U.S Passport
o Immunization Records
o Proof of Income: Public Assistance Letter within last 6
months or 1 Month of consecutive check stubs & 2014
tax records with listed dependents.
o Employer Information
o Photo I.D. of Parent/Guardian
o Proof of Address
(Utility Bill or lease agreement with
Parent name or notarized letter).
Riverside Traditional School
P.A.W.S Center Preschoolers Acheving the World through Social Skills
Paquete de Inscripción
2015-2016
Documentos Requeridos:
(Estos documentos deben ser sometidos con su aplicación)
o Acta de Nacimiento Original o Pasaporte de Los Estados
Unidos
o Expedientes de inmunización
o Prueba de Ingresos: Carta de Asistencia Pública con
fecha dentro de los últimos 6 meses o Impuestos del 2014
incluyendo sus dependientes y un mes de comprobantes
de pago consecutivos actuales
o Información de Empleo
o Identificación con Foto de Padre/Guardián
o Prueba de Domicilio
(Bill de utilidad o contracto de renta
O carta notariada)
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 R9-5-304.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 Provider*
Name: Contact Telephone Number:
*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
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: www.azdhs.gov/phs/immun/index.htm or contact the Arizona Immunization Program Office at (602)364-3630. 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): mo /day/ yr mo /day/ yr mo /day /yr
Updated immunizations received and attached: mo /day/ yr mo /day/ yr mo /day /yr
Medical Information
This Emergency Information and Immunization Record Card is accurate and complete, front and back, and was provided by:
G:\Forms\Emergency Information and Immunization Record Card (9/11) (4/14)
Is child allergic to food or other substances? If yes, describe symptoms, name foods or substances to be avoided, and the procedure to follow if reaction oc
No s:
Yes cur
Is child usually susceptible to infections and if so, what precautions need to be taken? If yes, list precautions:
No Yes
Is child subject to convulsions and what should be our procedure if one occurs? If yes, specify procedure:
No Yes
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:
Students Name (Nombre del estudiante) _________________________________
Ethnicity (Origen étnico): We are required to provide yearly information to the Office of Civil Rights and the Office of State Attendance
Records. (Se nos exige que proporcionemos información anualmente a la Oficina de Derechos Civiles y a la Oficina
Estatal de Registros de Asistencia).
Hispanic (Origen Latino) ___________Yes (Si) __________ No (No)
New Federal Regulations for Race/Ethnic Data (Nueva regulación federal para datos de raza/origen étnico):
________ White (Blanco) ________ Black/African American (Negro/Afroamericano) ________
Asian (Asiático)
________ Native American/Alaska Native (Indio Americano/Nativo de Alaska)
Tribal Name (Nombre de tribu): ________
________ Native Hawaiian or Other Pacific Islander (Nativo de Hawái o Otra Isla Pacifica)
The child lives with (El niño(a) vive con):
_______ Mother (Madre) _______ Father (Padre) _______ Mother & Father (Madre y Padre)
The following person/s may NOT remove my child from the school: (La siguiente persona/s NO puede/n retirar a mi hijo/a de la escuela: Name (Nombre) ______________________________ Name (Nombre) ______________________________
Custody papers have been provided and are on file at school: _____ Yes (Si) _____ No (No) (Documentos de custodia se han proporcionado y están en el archive de la escuela):
If separated or divorced, who has legal custody? ______________________________ (¿Si está separado/a o divorciado/a, quien tiene custodia legal?)
Does the other parent have visitation rights? _____ Yes (Si) _____ No (No) (¿Tiene el otro padre/madre derechos de visita?)
Please provide all legal paperwork. (Por favor proporcione todos los documentos legales.)
Parent’s/Guardian’s Signature (Firma del Padre/Guardián): ______________________ Date (Fecha): ________
Emergency Student Pick-Up Procedure
Dear Parents/Guardians,
Our facility is only authorized to release your child to either the parents/guardians as listed in
the child’s emergency contact form or any other person who the parent/guardian listed on the form. We
also know that even the best laid out plans sometimes fail. If you have an emergency and are unable to
pick your child up from preschool and if none of your listed emergency contact can pick up your child,
there is one more final option. You can give us verbal permission to release your child to another party.
Arizona State Licensure Department allows for verbal permission via the telephone ONLY if the facility
has a way to verify that the person calling is indeed the parent/guardian.
If you would like to use this as an option for dire emergency, you can place a code word into the
section below. Staff will only use this code word if the parent and/or guardian call to give us verbal
permission via the telephone. The Staff will check the photo identification card of the person you have
sent and compare it to the name you have given to us verbally. This person will need to sign your child
out on his/her daily attendance sheet.
I, _____________________________ parent/guardian of ______________________________ give
permission for my child to be released in case of an emergency only to a person of my choice through
verbal permission via the telephone in combination with the use of my code word. Please include the
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
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 R7-2-306(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.
1535 West Jefferson Street, Phoenix, Arizona 85007 • 602-542-0753 • www.azed.gov/oelas
Riverside Traditional School
P.A.W.S Center Preschoolers Acheving the World through Social Skills
1414 S 51st Ave
Phoenix, AZ 85043
(602) 272-1339
Por favor, mantenga esta sección con usted en todo momento en caso de una emergencia
Pasos a seguir en caso de una emergencia y ninguna persona de su forma de
emergencia puede recoger a su niño/a.
Llame a la oficina del programa preescolar P.A.W.S (602) 272-1339
1. De al personal su nombre y el nombre de su hijo/a
2. Informe al personal de su emergencia
3. De el nombre complete y una descripción de la/s persona/s que enviara a
recoger a su hijo/a
4. De al miembro del personal de su palabra clave
5. Insista en que la persona/s a que va/n a recoger a su niño/a traiga su
identificación con foto. Si la persona que designo para recoger a su niño/a
no sabe la palabra clave o no trae identificación el estudiante no será
liberado.
Riverside Traditional School
P.A.W.S Center Preschoolers Acheving the World through Social Skills
1414 S 51st Ave
Phoenix, AZ 85043
(602) 272-1339
Please keep this section with you at all times in case of an emergency
Steps to take in case of an emergency and no one on your child’s emergency
form can pick up your child.
1. Call the P.A.W.S Pre-School Center at (602) 272-1339
2. Give the staff member your name and child’s name.
3. Inform the staff member of your emergency
4. Give the full nameand description of the person(s) you will be sending to pick up
your child.
5. Give the staff member your code word.
6. Insist that the person/s picking up your child bring their ID. If the person you
designated to pick up your child does not have your code word or
picture ID your child will not be released.
Permission to Photograph and Film (Autorización para fotografiar y grabar video y filmar)
My signature below indicates my agreement to have my
child___________________________________ photographed and or video or film footage
used to enhance the educational environment and to market the P.A.W.S Pre-School Center. I
understand that I will receive no monetary compensation for the use of these photographs and
or video or film footage.
Mi Firma a continuación indica mi consentimiento para que mi hijo/a
____________________________ sea fotografiado, grabado en video, y/o filmado para
mejorar el ambiente educativo y promocionar el programa pre-escolar de P.A.W.S Entiendo que
no recibiré ninguna compensación monetaria por el uso de estas fotografías, video y/o
Por favor liste empleos adicionales e ingresos a continuación: : Empleo: Ingreso mensual o ingreso anual: ____________________ _______________________ ____________________ _______________________ ____________________ _______________________
Verifico que la información proporcionada en este formulario es correcta. Ha recibido una copia de esta solicitud.
Firma del Padre o Guardián Primario:
Fecha:
Firma del Padre o Guardián Secundario: Fecha:
Información de Empleo del Padre o Guardián Primario
Please list additional employment and income below: Employment Monthly Gross Income or Annual Gross Income ____________________ _______________________ ____________________ _______________________ ____________________ _______________________
I verify that the information provided on this form is accurate. I have received a copy of this application.