Genesis Academy Enrollment Packet

Genesis City A New Beginning for Youth
Student Name*
Date Received*

MonthDayYear
Date
SINCE 1991
Parent/Guardian to provide school with:
- Certified Birth Certificate
  - A baptismal certificate, an application for a social security number, original school registration records, an affidavit explaining the inability to provide a copy of the birth certificate, or a letter from the authorized representative of an agency having custody of the pupil will suffice as well.
- Proof of Residence
- Copy of Legal Custodial Guardianship papers (if applicable)
If you have any questions, please contact the office at (602)254-8090.

We are looking forward to serving as your educational partner.

Genesis Academy

Faculty and Staff
School Year*

Genesis Academy

Emergency/Health Information

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:
Name
Relationship
Home
Work
Cell
Is this person authorized to release the student?

YesNo
Name
Home
Work
Cell
Email
example@example.com
Is this person authorized to release the student?

YesNo
Name
Relationship
Home
Work
Cell
Email
example@example.com
Is this person authorized to release the student?

YesNo
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.
Please describe any existing health conditions
Any allergies
List all medications that the student is taking
Doctor's name
Phone
Hospital preference
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.
Signature of Parent/Guardian *

Clear
Date*

MonthDayYear
Date
Student Signature*

Clear
Date*

MonthDayYear
Date

Genesis Academy

Student Contract

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.

Technology

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.

Dress Code
- Clothing must cover areas from one armpit across to the other armpit, down to approximately 3 to 4 inches in length on the upper thighs. Tops must have shoulder straps.
- Shoes must be worn at all times and should be safe for the school environment (pajamas or slippers shall not be worn, except for school activities approved by the principal
- See-through or mesh garments must not be worn without appropriate coverage underneath that meet the minimum requirements of the dress code.
- Specialized courses may require specialized attire, such as sports uniforms or safety gear.
- Clothing may not depict, imply, advertise, or advocate illegal, violent, or lewd conduct, weapons, or the use of alcohol, tobacco, marijuana or other controlled substances.
- Clothing may not depict or imply pornography, nudity, or sexual acts.
- Clothing may not display or imply vulgar, discriminatory, or obscene language or images.
- Clothing may not state, imply, or depict hate speech/imagery targeting groups based on race, ethnicity, gender, sexual orientation, gender identity, religious affiliation, or any other protected classification.
- Apparel, jewelry, accessories, tattoos, or manner of grooming that, by virtue of its color, arrangement, trademark or any other attribute, denotes membership in a gang that advocates illegal or disruptive behavior is prohibited.
Parent/Guardian Consent

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.
Student Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

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.
1. What language do people speak in the home most of the time?*
2. What language does the student speak most of the time?*
3. What language did the student first speak or understand?*
Student Name
District Student ID
Date of Birth

MonthDayYear
Date
SSID
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
District or Charter
School
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)

Office of English Language Acquisition Services

1535 West Jefferson Street * Phoenix, Arizona 85007 * 602-542-0753 www.azed.gov/oelas

Arizona Residency Documentation Form
Student*
School District or Charter Holder: Genesis Program Inc
Parent/Legal Guardian *
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:
- Valid Arizona driver’s license, Arizona identification card or motor vehicle registration
- Valid U.S. passport
- Real estate deed or mortgage documents
- Property tax bill
- Residential lease or rental agreement
- Water, electric, gas, cable, or phone bill
- Bank or credit card statement
- W-2 wage statement
- Payroll stub
- Certificate of tribal enrollment or other identification issued by a recognized Indian tribe that contains an Arizona address.
- Documentation from a state, tribal or federal government agency (Social Security Administration, Veteran’s Administration, Arizona Department of Economic Security)
- Temporary on-base billeting facility (for military families)
- I am currently unable to provide any of the foregoing documents. Therefore, I have provided an original affidavit signed and notarized by an Arizona resident who attests that I have established residence in Arizona with the person signing the affidavit
Signature of Parent/Legal Guardian*

Clear
Date*

MonthDayYear
Date

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:
- Consent before students are required to submit to a survey that concerns one or more of the following protected areas (“protected information survey”) if
  the survey is funded in whole or in part by a program of the U.S. Department of Education (ED)–
  1. Political affiliations or beliefs of the student or student’s parent;
  2. Mental or psychological problems of the student or student’s family;
  3. Sex behavior or attitudes;
  4. Illegal, anti-social, self-incriminating, or demeaning behavior;
  5. Critical appraisals of others with whom respondents have close family relationships;
  6. Legally recognized privileged relationships, such as with lawyers, doctors, or ministers;
  7. Religious practices, affiliations, or beliefs of the student or parents; or
  8. Income, other than as required by law to determine program eligibility.
- Receive notice and an opportunity to opt a student out of –
  1. Any other protected information survey, regardless of funding;
  2. Any non-emergency, invasive physical exam or screening required as a condition of attendance, administered by the school or its agent, and not necessary
  to protect the immediate health and safety of a student, except for hearing, vision, or scoliosis screenings, or any physical exam or screening permitted or
  required under State law; and
  3. Activities involving collection, disclosure, or use of personal information obtained from students for marketing or to sell or otherwise distribute the
  information to others.
- Inspect, upon request and before administration or use –
  1. Protected information surveys of students;
  2. Instruments used to collect personal information from students for any of the above marketing, sales, or other distribution purposes; and
  3. Instructional material used as part of the educational curriculum.
  These rights transfer to from the parents to a student who is 18 years old or an emancipated minor under State law.
  Genesis Academy has developed and adopted policies, in consultation with parents, regarding these rights, as well as arrangements to protect student privacy
  in the administration of protected information surveys and the collection, disclosure, or use of personal information for marketing, sales, or other distribution
  purposes. Genesis Academy will directly notify parents of these policies at least annually at the start of each school year and after any substantive changes.
  [School District] will also directly notify, such as through U.S. Mail or email, parents of students who are scheduled to participate in the specific activities or
  surveys noted below and will provide an opportunity for the parent to opt his or her child out of participation of the specific activity or survey. Genesis
  Academy will make this notification to parents at the beginning of the school year if the District has identified the specific or approximate dates of the
  activities or surveys at that time. For surveys and activities scheduled after the school year starts, parents will be provided reasonable notification of the
  planned activities and surveys listed below and be provided an opportunity to opt their child out of such activities and surveys. Parents will also be provided
  an opportunity to review any pertinent surveys. Following is a list of the specific activities and surveys covered under this requirement:
- Collection, disclosure, or use of personal information for marketing, sales or other distribution.
- Administration of any protected information survey not funded in whole or in part by ED.
- Any non-emergency, invasive physical examination or screening as described above.
  
  Parents who believe their rights have been violated may file a complaint with:
  Family Policy Compliance Office
  U.S. Department of Education
  400 Maryland Avenue, SW
  Washington, D.C. 20202-8520
Should be Empty:

Household Size	Yearly	Monthly	Weekly
1	$32,606	$1,968	$454
2	$31,894	$2,658	$614
3	$40,182	$3,349	$773
4	$48,470	$4,040	$933
5	$56,758	$4,730	$5,421
6	$65,046	$5,421	$1,251
7	$73,334	$6,112	$1,411
8	$81,622	$6,802	$1,570
Each Additional Person:	+$8,288	+$691	+$160

Genesis City A New Beginning for Youth

SINCE 1991