New Student Registration - Griffin Foundation

Choose Only One*

Children Reaching for the Sky Preparatory (K – 5th grade)
Future Investment Middle School (6th – 8th grade)

You will need to provide a proof of residency to the school.

Student Information

Student Name*

First Middle Last

Age*

Date of Birth*

Place of Birth*

Gender*

Male
Female

Student Grade Level for 21/22 School Year*

Parent Information

Parent Name*

Contact Number*

Mother's Email

Father's Email

Home Address

Street Address Address Line 2 City State ZIP Code

Is at least one parent/guardian a member of the Armed Forces on active duty?

Yes
No

Home Phone

Work Phone

Cell Phone

Parent Signature*

Last School Attended

Name of School*

District*

Last School Address

School Address City State

Reason for leaving previous school:

Date student last attended school:*

Transportation

Please Mark Types Below

Walker
Parent Transport
Bike
Carpool
Public Bus
Daycare

Day(s) of pick-up (Daycare):

Monday
Tuesday
Wednesday
Thursday
Friday

Emergency Information

Student Lives With:*

Name of person (persons) who have Legal Custody:

Mother/Guardian Name:

First Middle Last

Mother/Guardian Home Phone

Mother/Guardian Work Phone

Mother/Guardian Employer

Father/Guardian Name:

First Middle Last

Father/Guardian Home Phone

Father/Guardian Work Phone

Father/Guardian Employer

In case of an emergency, our procedure is to contact the parent/guardian that is listed first on the Student Data form at work or home. If we are unable to contact you, the second person listed on this form will become the next person to contact. The seriousness of the issue will determine whether or not the persons listed below will be asked to care for your child. A rescue unit will be called in a serious situation.

Person(s) who will care for and transport the student if the parent(s) cannot be contacted:

Emergency Contact Person 1 Name*

Emergency Contact Person 1 Relationship*

Emergency Contact Parson 1 Daytime Phone*

Emergency Contact Parson 1 Cell Phone*

Emergency Contact Person 2 Name*

Emergency Contact Person 2 Relationship*

Emergency Contact Parson 2 Daytime Phone*

Emergency Contact Parson 2 Cell Phone*

Emergency Contact The following person(s) may NOT remove my child from the school:

If so, comment?

Please check one of the boxes below:

I give permission for my child to be photographed for all educational purposes, including school yearbook, media/social media, and online advertisements without reservation or compensation.
I do not give permission for my child to be photographed for school purposes for any reason.

Signature*

Name

First Last

Home Phone

Work/Cell Phone

Student Background Information

Student's Name

First Middle Last

Disclaimer: The questions below are only asked for continuation of services and are not a condition of enrollment.

Has the student ever been expelled from any school?*

Yes
No

If yes, please explain:

Has the student ever had behavior issues in school?*

Yes
No

Has the student ever had attendance issues in school?*

Yes
No

If Yes, explain:

Has the student ever been or currently under the supervision of a Juvenile Court?*

Yes
No

If Yes, explain:

Does the student have any conditions that require special accommodations?*

Yes
No

If yes, list the conditions and/or accommodations needed:

Has the student ever skipped a grade?*

Yes
No

If yes, identify the grade level:

Has the student ever repeated/retained a grade?*

Yes
No

If yes, identify the grade level:

What are your goals and expectations of the school and your child?

How did you learn about the Griffin Foundation School District?

Brochure, Flyers, and Handout
Government Advertisement
Internet/Media Online Sites
Griffin Foundation’s Website
Walk-in
Relative
Friend
Newspapers/Television/Radio: Station/Name

Name of Reference:

Enrollment Information

Student's Name*

First Middle Last

Disclaimer: The questions below are only asked for continuation of services and are not a condition of enrollment.

To promptly serve the student, do you have the most current IEP?*

Yes
No

Has student ever attended English Language Learner (ELL) Classes?*

Yes
No

Has student ever been designated as Limited English Proficiency (LEP) or as an English Learner?*

Yes
No

Disclaimer: The questions below are only asked for continuation of services and are not a condition of enrollment.

Race/Ethnicity Two-Part Question: Complete both questions:

Part 1: Ethnicity (Choose one only)*

Yes, Hispanic or Latino American Indian or Alaska Native A person of Mexican, Puerto Rico, Cuban, South or Central Asian American or other Spanish culture or origin, regardless of race
No, not Hispanic or Latino

Part 2: Race (Choose one or more)*

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

McKinney-Vento Act Eligibility:

Is your current address a temporary living arrangement?*

Yes
No

How long have you been at current address?

Is this temporary living arrangement due to loss of housing or economic hardship?

Yes
No

Where is the student currently living? (If applicable, check one box)

In a Shelter
In a Motel
With more than one family in a house or apartment
In a place not designed for ordinary sleeping accommodations (ex. car, park, campsite)

PHLOTE (Primary Home Language other than English):

What is the primary language used in the home regardless of the language spoken by the Student?*

What is the language most often spoken by the student?*

What is the language that the student first acquired?*

Name(s) of Parent(s)/Legal Guardian(s):*

First Last

Student Health Record

Name

First Middle Last

Date of Birth

* Optional to answer for enrollment.

The following information is helpful in assessing your child’s health and learning. Has your child ever had any of the following? If “Yes” please give the child’s age at that time.

Allergies

No
Yes

Allergies Age

Anemia

No
Yes

Anemia Age

Arthritis

No
Yes

Arthritis Age

Asthma

No
Yes

Asthma Age

Bleeding Disorder

No
Yes

Bleeding Disorder Age

Birth Trauma

No
Yes

Birth Trauma Age

Cerebral Palsy

No
Yes

Cerebral Palsy Age

Chicken Pox

No
Yes

Chicken Pox Age

Cystic Fibrosis

No
Yes

Cystic Fibrosis Age

Developmental Delays

No
Yes

Developmental Delays Age

Diabetes

No
Yes

Diabetes Age

Epileptic Seizures

No
Yes

Epileptic Seizures Age

Frequent Colds

No
Yes

Frequent Colds Age

Frequent Sore Throats

No
Yes

Frequent Sore Throats Age

Headaches

No
Yes

Headaches Age

Heart Disease Problems

No
Yes

Heart Disease Problems Age

Hepatitis

No
Yes

Hepatitis Age

High Blood Pressure

No
Yes

High Blood Pressure Age

Kidney Infection

No
Yes

Kidney Infection Age

Mumps

No
Yes

Mumps Age

Pneumonia

No
Yes

Pneumonia Age

Rheumatic Fever

No
Yes

Rheumatic Fever Age

Scarlet Fever

No
Yes

Scarlet Fever Age

Scar Latina

No
Yes

Scar Latina Age

Scoliosis/Curvature

No
Yes

Scoliosis/Curvature Age

Sickle Cell Anemia

No
Yes

Sickle Cell Anemia Age

Strep Throat

No
Yes

Strep Throat Age

Tonsillitis

No
Yes

Tonsillitis Age

Urinary Infections

No
Yes

Urinary Infections Age

Vision Problems

No
Yes

Vision Problems Age

Other (include age)

If you answered “Yes” to any of the above, Please explain below.

Month/Year of student’s last physical examination:

What was the purpose of this exam?

Has your child ever had:

Surgery?

No
Yes

Surgery Age

Serious accident or injury?

No
Yes

Serious accident or injury Age

Tubes in his/her ears?

No
Yes

Tubes in his/her ears Age

* Optional to answer for enrollment.

Does your child presently have:

Dietary restrictions?

No
Yes

Vision difficulties?

No
Yes

Hearing difficulties?

No
Yes

Hearing aids?

No
Yes

Tubes in his/her ears?

No
Yes

Emotional problems?

No
Yes

Attention deficit disorder?

No
Yes

Other learning disabilities?

No
Yes

Receiving medical treatment?

No
Yes

Taking medication on a daily basis?

No
Yes

Name of Medicine

Restricted from physical education, sports, etc.?

No
Yes

Please explain any “Yes” answers:

Are there any cultural, social, or religious patterns that you would like the teachers to know about? Please explain below:

Has the student ever been or currently under the supervision of a Juvenile Court?*

No
Yes

Please Explain:

Has the student ever been or currently under the supervision of a Juvenile Court?

Medical Emergency

In case of serious illness or injury, I give consent for my child to be taken to the closest hospital by school personnel or ambulance and given emergency care until I can be reached.*

Yes
No (If No, please fill out the doctor name and hospital information below.)

Doctor Name

Doctor Address

Street Address City State ZIP Code

Doctor Phone

Hospital Name

Hospital Address

Street Address City State ZIP Code

Hospital Phone

Medical Insurance company

Policy Number:

List all medications, conditions, and allergies:

We give permission to the Griffin Foundation School District to administer the following medications:

Acetaminophen (Tylenol)*

Yes
No

Antacid (Tums/Rolaids)*

Yes
No

Pepto-Bismol*

Yes
No

Neosporin Ointment*

Yes
No

Cough Drops*

Yes
No

Benadryl*

Yes
No

Authorization for Student Pick up

Student's Name*

First Middle Last

Grade*

Please list relatives or friends who may pick up your son/daughter from GFSD during this school year that you have not already listed as an Emergency Contact.

Pickup Authorization Person 1 Name

Pickup Authorization Person 1 Relationship

Pickup Authorization Person 1 Home Phone

Pickup Authorization Person 1 Cell Phone

Pickup Authorization Person 2 Name

Pickup Authorization Person 2 Relationship

Pickup Authorization Person 2 Home Phone

Pickup Authorization Person 2 Cell Phone

Pickup Authorization Person 3 Name

Pickup Authorization Person 3 Relationship

Pickup Authorization Person 3 Home Phone

Pickup Authorization Person 3 Cell Phone

Pickup Authorization Person 4 Name

Pickup Authorization Person 4 Relationship

Pickup Authorization Person 4 Home Phone

Pickup Authorization Person 4 Cell Phone

Pickup Authorization Person 5 Name

Pickup Authorization Person 5 Relationship

Pickup Authorization Person 5 Home Phone

Pickup Authorization Person 5 Cell Phone

List the Daycare authorized to provide transportation for your child:

Daycare Name

Daycare Address

Street Address City State ZIP Code

Daycare Phone

Daycare Contact Person

Days daycare is scheduled to transport your child from GFSD:

Monday
Tuesday
Wednesday
Thursday
Friday

Consent

I agree to the below:

My child and I do understand the GFSD’s policies and procedures as listed in the handbook such as but not limited to the uniform policy, attendance policy, coat policy, and school procedures regarding cell phones, electronics, internet use, gum chewing, modest facial make-up, unnatural hair colors and style, tattoos, piercings, and
acceptable foods. The information can be found in a binder at the front office, school handouts, or on our website.

Parent Signature*

Transfer of Records Request

Mail To:

Children Reaching for the Sky Preparatory (K – 5th grade) 1844 S. Alvernon Way, Tucson, AZ 85711
Future Investment Middle School (6th – 8th grade) 1854 S. Alvernon Way, Tucson, AZ 85711

Student's Name

First Middle Last

Student's Grade

Students Birthdate

Gender

Male
Female

Parent's/ Guardian's Name

Additional Siblings’ records requested?

Yes
No

Sibling 1 Name

Sibling 1 Birthdate

Sibling 1 Age

Sibling 1 Grade

Sibling 2 Name

Sibling 2 Birthdate

Sibling 2 Age

Sibling 2 Grade

Previous School Attended by student:

Date of Entry

Date of Exit

Previous School Address

Street Address City State ZIP Code

Previous School Phone Number

Previous School Fax Number

I herby authorize the above referenced school to release the following records listed below to:

*Student AzEDS Identity Number

Please Note: The student information requested will be made available for inspection to parents/guardians/eligible students since it will be considered an education record as defined in Public Law 93-380, Section 99:3
PL 93-380, The Federal Family Educational Rights and Privacy Act, Arizona Law, ARS 15-151, District Board Policy 5130, and Administrative Regulations provide that the written consent of the parent/guardian/eligible student IS NOT REQUIRED to release educational records to officials of other schools or school systems in which the student seeks or intends to enroll.

GRIFFIN FOUNDATION SCHOOL DISTRICT
1844 S. Alvernon Way, Tucson, AZ 85711
Office: 520-790-8400