Parent/Guardian to provide school with:
If you have any questions, please contact the office at (602)254-8090.
We are looking forward to serving as your educational partner.
Faculty and Staff
Genesis Academy Registration Form
Physical Address (if different from above) City
Academic Information (Information provided below is not a condition of enrollment)
Home Language Survey
McKinney-Vento Eligibility Questionnaire
The McKinney-Vento Homeless Assistance Act (Title X, Part C, of the No Child Left Behind Act) defines "homeless" as "individuals who lack a fixed, regular, and adequate nighttime residence." This includes children who "are temporarily sharing the housing of other persons due to the loss of housing or economic hardship.' Information on this form is confidential and is not shared or used for any other purposes.
IF YOU ANSWERED "NO" to ALL QUESTIONS, PLEASE SIGN BELOW. THANK YOU.
Responses to the rest of this page are also voluntary and will tell us that you are interested in possible services under McKinney-Vento. If you answered "yes" to any of the questions above, please fill out the remainder of this form.
In case of an emergency, our procedure is to contact the parent/guardian that is listed first on the Registration Form at work or home. If we are unable to contact the parent/guardian, the first person listed on this form will become the next person who will be contacted. The seriousness of the issue will determine whether or not he/she will be asked to care for your child. A rescue unit will be called in an emergency situation.
Person(s) who will care for and transport the student if the parent/guardian(s) cannot be reached:
In the event of a medical emergency, I give permission for my child to be taken to the nearest medical facility to receive medical care while he/she is attending Genesis Academy. I understand that it is my responsibility to contact the hospital or medical facility and arrange for payment of all emergency services rendered.
Students cannot attend school unless they comply with Arizona State Statute Section 15-872, Subsection E, which states that current immunizations must be on file.
Genesis Academy does not employ a school nurse; therefore, school staff and /or students cannot administer medication. We maintain a basic first aid supply cabinet at the school.
I understand that admission to the Genesis Academy is a privilege; therefore, I will follow all regulations and policies as outlined in the Genesis Academy Student Manual.
I also understand that it is possible that I might be using technology such as the internet to access, produce, publish and communicate information for research purposes. Along with this privilege, I will show respect for the technology and will use it appropriately or I will forfeit this opportunity. The signatures at the bottom grant my child access to the internet at Genesis Academy.
I support my child's registration in the Genesis Academy and understand that I will be expected to attend information sessions and other activities connected to my child's success. I am also aware of all of the student policies outlined in the Genesis Academy Student Manual (including our policy on drug screening, zero tolerance on violence and search and seizure) and support the school's full enforcement of these policies as they pertain to my child. My child has my approval to enroll in college credit courses and I agree to the exchange of academic information between the participating institutions. By signing this form, I understand that the school may utilize my child's photographs or that my student may be filmed for marketing media and public relations (i.e., brochures, websites, advertising, TV news segments, etc Upon your child's 18th birthday, the Academy may no longer release information to the student's parent/guardian. Please have your child sign the following release in order to continue receiving academic progress and behavioral information regarding your child after his/her 18th birthday.
Arizona Department of Education
Office of English Language Acquisition Services
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.
Please provide a copy of the Home Language Survey to the EL Coordinator/Main Contact on site. In AzEDS, please enter all three HLS responses. (R7-2-306(B1),(2a-c) (Revised 01-2020)
1535 West Jefferson Street * Phoenix, Arizona 85007 * 602-542-0753 www.azed.gov/oelas
Arizona Residency Documentation Form
School District or Charter Holder: Genesis Program Inc
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:
*This is not a condition of enrollment*
The following form is to determine if the student is eligible to receive services associated with the
"No Child Left Behind Act" of 2001
If your family qualifies, please complete the following information for each child:
FEDERAL ELIGIBILITY INCOME CHART
Children's racial and ethnic identities (optional):
Signature (Adult must sign)An adult household member must sign the application.I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get Federal funds based on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my children may lose benefits, and I may be prosecuted.
APPENDIX A ANNUAL NOTIFICATION
To: Workers, Building Occupants or their Legal Guardians, Tradesmen, and Outside Service Providers
From: Genesis Academy
525 W. McDowell Rd, Phoenix, Arizona
Reference: Asbestos Hazard Emergency Response Act (AHERA) 40 CFR Part 763-
Asbestos-Containing Materials in Schools; Final Rule and Notice, October 30. 1987, 763.84, Local Educational Agency (LEA) responsibilities.
Notification is required to inform building occupants at least once each school year about inspections, response actions, and post –response action activities, including periodic reinspection and surveillance activities that are planned or in progress at each school K-12 in accordance with AHERA.
Asbestos materials were not identified within the onsite school structures. The EPA requires an asbestos Management Plan (MP). The MP (dated July 2019) is available for review at the administration office of the campus
If you have any questions, please contact the Designated Person listed below:
Designated Person: Mr. Grayson Payne
Telephone #: (602)-254-8090
Notification of Rights under FERPA for Elementary and Secondary Schools
The Family Educational Rights and Privacy Act (FERPA) affords parents and students over 18 years of age ("eligible students") certain rights with respect to the student's education records. These rights are:(1) The right to inspect and review the student's education records within 45 days of the day the School receives a request for access. Parents or eligible students should submit to the School principal [or appropriate school official] a written request that identifies the record(s) they wish to inspect. The School official will make arrangements for access and notify the parent or eligible student of the time and place where the records may be inspected. (2) The right to request the amendment of the student’s education records that the parent or eligible student believes are inaccurate, misleading, or otherwise in violation of the student’s privacy rights under FERPA.Parents or eligible students who wish to ask the School to amend a record should write the School principal [or appropriate school official], clearly identify the part of the record they want changed, and specify why it should be changed. If the School decides not to amend the record as requested by the parent or eligible student, the School will notify the parent or eligible student of the decision and advise them of their right to a hearing regarding the request for amendment. Additional information regarding the hearing procedures will be provided to the parent or eligible student when notified of the right to a hearing.(3) The right to consent to disclosures of personally identifiable information contained in the student's education records, except to the extent that FERPA authorizes disclosure without consent.One exception, which permits disclosure without consent, is disclosure to school officials with legitimate educational interests. A school official is a person employed by the School as an administrator, supervisor, instructor, or support staff member (including health or medical staff and law enforcement unit personnel); a person serving on the School Board; a person or company with whom the School has contracted as its agent to provide a service instead of using its own employees or officials (such as an attorney, auditor, medical consultant, or therapist); or a parent or student serving on an official committee, such as a disciplinary or grievance committee, or assisting another school official in performing his or her tasks.A school official has a legitimate educational interest if the official needs to review an education record in order to fulfill his or her professional responsibility.[Optional] Upon request, the School discloses education records without consent to officials of another school district in which a student seeks or intends to enroll. [NOTE: FERPA requires a school district to make a reasonable attempt to notify the parent or student of the records request unless it states in its annual notification that it intends to forward records on request.](4) The right to file a complaint with the U.S. Department of Education concerning alleged failures by the School District to comply with the requirements of FERPA. The name and address of the Office that administers FERPA are at the end of the document:
Notification of Rights Under the Protection of Pupil Rights Amendment (PPRA)
PPRA affords parents certain rights regarding our conduct of surveys, collection and use of information for marketing purposes, and certain physical exams. These include the right to: