16850 N. 16th Street Phoenix, AZ 85022
Please complete the form below. Required fields marked with an asterisk *
ONLY MILITARY FAMILIES NEED TO FILL OUT THIS SECTION
Arizona Department of Health Services
Bureau of Child Care Licensing
Emergency, Information and Immunization Record Card
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.)
If Medical care is necessary, call Health Care Provider (A Health Care Provider is a physician, physician assistant or registered nurse practitioner.)
I hereby give authority to any hospital or doctor to render immediate aid as might be required at the time for his/her health and safety.
(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.
This Emergency Information and Immunization Record Card is accurate and complete, front and back, and was provided by:
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. § 15-823(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 responsiblility 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.
A. R. S. § 15-802(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. § 15-802 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 of physical description of the property where the student resides (no P.O. Boxes):
Valid Arizona driver’s license, Arizona identification cardValid Arizona motor vehicle registrationValid United States passportProperty deedMortgage documentsProperty tax billRental agreement or lease (including Section 8 agreement)Utility bill (water, electric, gas, cable, phone)Bank or credit card statementW-2 wage statementPayroll stubCertificate of tribal enrollment or other identification by a recognized Indian tribeOther 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: https://www.azed.gov/finance/files/2011/10/arizona-residencyguidelines.pdf .
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.
Arizona Department of Education / Arizona Residency Documentation Form
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.
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.
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.
Part 1: Ethnicity
Part 2: Race
I hereby authorize my child to be photographed/videoed by Kaleidoscope School for any or all of the purposes marked below.
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.
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.
Before and Aftercare Program Registration Fee
One Time Registration Fee - $50.00
Before Care is offered Monday through Friday 7:00am - 8:00am
Aftercare is offered Monday through Friday 3:00pm - 6:00pm
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.