Kaleidoscope School Registration

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Immunization Record Upload
Student's Name *

Last Name First Name Middle Name Suffix
Please attach a copy of the student's immunization record here. *

Cancel of
Parent / Guardian Signature *

Clear
Date *

Month Day Year
Date

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Birth Certificate Upload
Student's Name *

Last Name First Name Middle Name Suffix
Please attach a copy of the student's birth certificate here. *

Cancel of
Parent / Guardian Signature *

Clear
Date *

Month Day Year
Date

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Elementary School Student Records Request
Student's Name *

Last Name First Name Middle Name Suffix
Student's Date of Birth *

Month Day Year
Date
Name of school student last attended *
School's Address *

Street Address

Street Address Line 2

City State

Zip Code
School's Phone Number
Please enter a valid phone number.
School's Email Address *
example@example.com
District Name *
In accordance with Arizona Revised Statute 15-828, I authorize the release of all records, including birth certificate, academic, educational, medical (health), psychological, special education, social development, and gifted information to Kaleidoscope School, an Arizona charter school.
Parent / Guardian Name *

First Name Last Name
Parent / Guardian Signature *

Clear
Date *

Month Day Year
Date

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Elementary School Home Language Survey - English
Arizona Department of Education

Office of English Language Acquisition Services

Home Language Survey

The responses to this Home Language Survey (HLS) are used by the school to provide the most appropriate instructional programs and services for the student. The answers below will determine if a student will take the Arizona English Language Learner Assessment (AZELLA). Please respond to each of the three questions as accurately as possible. If you need to correct any of your responses, this must be done before the student takes the AZELLA Placement Test.
What language do people speak in the home most of the time? *
What language did the student first speak or understand? *
Student's Name *

Last Name First Name Middle Name Suffix
Student's Date of Birth *

Month Day Year
Date
Parent / Guardian Name *

First Name Last Name
Parent / Guardian Signature *

Clear
Date *

Month Day Year
Date

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Race and Ethnicity Data
RACE and ETHNICITY DATA COLLECTION FORM

In accordance with new federal guidance, schools are required to utilize a two-part question to collect data about race and ethnicity. Part 1 is in reguards to Ethnicity and part 2 relates to race. More than one race may now be selected in part 2.

Race/Ethnicity Two-Part Questions: Answer Both questions.
Today's Date *

Month Day Year
Date
Child's Name *

Last Name First Name Middle Name Suffix
Part 1: Ethnicity
Is the student Hispanic or Latino? (Choose only one) *

No, not Hispanic or Latino Yes, Hispanic or Latino (A person of Mexican, Puerto Rica, Cuban, South or Central American, or other Spanish culture or origin, regardless of race.)
Part 2: Race
What is the student's race? (Regardless of how respondent answered the first question, choose one or more) *

American Indian or Alaska Native (A person having origins in any of the original tribal peoples of North and South America, including Central America, and who maintains affiliation or community attachment.) Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.) Black or African American (A person having origins in any of the black racial groups of Africa.) Native Hawaiian or Other Pacific islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.) White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.)
Parent / Guardian Name *

First Name Last Name
Parent / Guardian Signature *

Clear

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Elementary School Media Release Form
I hereby authorize my child to be photographed/videoed by Kaleidoscope School for any or all of the purposes marked below.
Student's Name *

Last Name First Name Middle Name Suffix
To place on the internet for marketing of the school only. *

Yes No
To display in the school office. *

Yes No
To place on any marketing items for Kaleidoscope (ie, banners, flyers, postcards). *

Yes No
Date *

Month Day Year
Date
Parent / Guardian Name *

First Name Last Name
Parent / Guardian Signature *

Clear

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Handbook Acknowledgement
Kaleidoscope School Handbook

HANDBOOK ACKNOWLEDGEMENTS AND VERIFICATIONS

By signing below, you are acknowledging and verifying that you have taken the responsibility to review with your child the Kaleidoscope School Parent Handbook (available online at Kaleidoscope Handbook or request a copy from the school office).

As a parent of Kaleidoscope School, you have the right to a quality education for your child/children. To make sure that every student enjoys that right, the school has established procedures regarding disruptive behavior.

The procedures for student responsibility are designed to create an orderly environment that is safe for all students and staff.

The rules are reasonable and fair and they are the same in each classroom. We ask that you read carefully the infractions and disciplinary actions for conduct with your child.
Student's Name *

Last Name First Name Middle Name Suffix
Grade *
Please Note: Federal privacy laws prohibit the school from naming students involved in disciplinary actions and from revealing the consequences of those actions to the parents of other students. Please refer to the discipline matrix for guidance on infractions and consequences.
Parent / Guardian Name *

First Name Last Name
Parent / Guardian Signature *

Clear
Date *

Month Day Year
Date
Student's Signature *

Clear
Date *

Month Day Year
Date

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Elementary Before and Aftercare Fee Schedule
Student's Name *

Last Name First Name Middle Name Suffix
Before and Aftercare Program Registration Fee

One Time Registration Fee - $50.00

Before Care is offered Monday through Friday 7:00am - 8:00am

$50.00/Month

Aftercare is offered Monday through Friday 3:00pm - 6:00pm

$150.00/Month

10% Sibling Discount

Drop in Before and Aftercare is available for $30.00/Day (Cash Pay Only)

All registration and fees must be completed prior to the 1st of each month. If payment is recieved after the 5th of the month, there will be a $5.00/day late charge.

In the event a student is absent for 10 consecutive days without a doctor's note, the student will be automatically withdrawn. The ability to re-enroll is subject to availability and cannot be guaranteed.
Parent / Guardian Name *

First Name Last Name
Parent / Guardian Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

Kaleidoscope School Registration

Elementary School Emergency-Info-Immunization-Card

Immunization Record Upload

Birth Certificate Upload

Arizona Department of Education / Arizona Residency Guidelines

Elementary School Student Records Request

Elementary School Home Language Survey - English

Race and Ethnicity Data

Elementary School Media Release Form

Handbook Acknowledgement

Elementary Before and Aftercare Fee Schedule