Phoenix College

Nrume: ___________________ __
Grade:-:------ ----Received:
------------
,..,.
Phoenix
College
Preparatory Academy
All students interested in enrolling at Phoenix College Preparatory Academy (PCPA) must submit a completed
application packet. Please be sure to respond to all parts of the application and have parents/guardians
read the application and sign. The following documents are considered MANDATORY for your application
to be complete.
Todos los estudiantes interesados en matricularse en Ia Academia de Phoenix College Preparatory debe presentar un
paquete de aplicaci6n completo. Por favor, asegfuese de responder a todas las partes de Ia aplicaci6n y que los padres I
tutores leido Ia aplicaci6n y fmnar. Los siguientes documentos se consideran de obligado cumplimiento para que su
aplicaci6n sea completa.
Enrollment Checklist!lnscripci on Lista
D
D
D
D
PCPA Application!Aplicacion de Phoenix College Preparatory Academy
Records Request Form!Formulario de Solicitud de Registros
Ethnic/Race Data Information Sheetletnico I raza Hoja de Datos de Informacion
Residency Documentation Form or Affidavit!Formulario de Documentacion de Residencia o
Declaraci6n Jurada
D
D
D
D
D
D
D
Home Language Survey (PHLOTE)/Encuesta sabre el Idioma en el Hagar
McKinney-Vento Survey/Encuesta de McKinney- Vento
Field Trip Permission Slip/Excursion Permiso
Off-Campus Permission Slip/Permiso Fuera del Campus
Photo Consent Form/ Formulario de Consentimiento de Fotos
Travel Assumption Form/Forma de Viaje Asuncion
Copy oflndividual Education Plan (IEP) (if applicable)/Copia de Plan de Educacion Individual
D
D
D
(si se aplica)
Birth Certificate/Certlfzcado de Nacimiento
Immunizations/Vacunas
8th Grade Promotion Certificate (incoming 9'h graders only)/Certlfzcado del Octavo Grado
(entrantes go grado solo)
STUDENTS WHO PREVIOUSLY ATTENDED IDGH SCHOOL
ESTUDIANTES QUE PREVIAMENTE A LA ESCUELA SECUNDARIA
D Withdrawal Form (if transfer student)/Formulario de Retiro (si es estudiante de transferencia)
D Unofficial Transcript (if transfer student)/Transcripcion no oficial (si es estudiante de transferencia)
D Attendance and Discipline Records/Registros de Asistencia y Disciplina
How did you hear about Phoenix College Preparatory Academy? (Check all that apply)
(.C6mo se enter6 acerca de Phoenix College Preparatory Academy? (Marque todos los que apliquen)
Relatives/Familiares
Friends/Amigos
Website/Internet
Flyer(volante)
_
-
TV
Presentation (where was the presentation?)/Presentaci6n (;,donde fue Ia presentaci6n?) - - - - - - - - - - - - - - PCPA Student (name of student)/Estudiante de PCPA (nombre del estudiante) - - - - - - - - - School Counselor (which schooi?)/Consejero Escolar (i,.cual escuela) - - - - - - - - - - - - - - Newspaper (name ofnewspaper)/Peri6dico (nombre del peri6dico) - - - - - - - - - - - - - - - - Other (please indicate)/Otro (por favor indique)
1202 West Thomas Road, OSE105 + Phoenix, AZ 85013 + Phone 602.285.7998 +Fax 602.285.7697
~
For OfTiu; Us<::
Date enrolled:
Enrollment Co~
Date Entered in Schoolmaster:
Date Withdrawn:
------o;de
~.,~ Phoenix
College
Preparatory Academy
-
-·
Student Information/Informacion del Estudiante:
Last Name!Apellido:
First Name! Hombre:
Current Grade Level/Nivel de Grado:
MI. - - -
Gender/Sexo: Male
Birthdate/Fecha de Nacimiento:
Month/Mes:
Date/Fecha
Year/Ana:
Female
I SAISID#
I
4. Age!Edad:
Student's Address!Domicilio de estudiante;
City/Cuidad:
Zip Code/Area Postal
Student's home telephone number!Numero de telifono de casa de estudiante;
House/Casa ( )
Other!Otro: (
)
E-mail:
Mother's/Guardian Information/ Informacion de Madre/Tutor:
Last Name! Apellido:
First Name!Nombre:
Telephone!telefono: House/Casa:( )
Work! trabajo: ( )
E-mail:
Father's/Guardian Information/Informacion de Padre/Tutor:
Last Name! Apellido:
First Name!Nombre:
Telephone!telefono: House!Casa:( )
Work! trabajo: ( )
E-mail:
Emergency Contactlcontacto de emergencia;
Name!Nombre:
Otro: (
)
Otro: (
)
Telephone!Telefono:
(
)
Student lives with:/Estudiante vive con:
Both Parents
Father
Mother
Los Padres
Padre
Madre
Is your student currently in Special Education? Yes
Recibe su estudiante clase de Educacion Especial? Si
Grandparent
Abuelo(a)
No
No
Other
Otra:
Ifyes, please include copy ofIEP
Si es, par favor incluya una copia del IEP
School last attended!Escuela atendio anteriormente- Dates attended/fechas de asistencia
Parent/Guardian Signature/Firma de Padres/Guardian
Maricopa Community College District draws no inference about an individual's citizenship or immigration status based upon your answers to these questions.
Phoenix College Preparatory Academy is a.free public high school and does not require any citizenship or immigration status information or documentation to
enroll students into high school classes. Students are not required to take college courses and are enrolled on a first come,first served, basis.
Maricopa Community College District no establece ninguno injerencio ocerco de Ia ciudadanfo de uno persona o situoci6n migrotorio, tompoco se bose en sus
respuestas a estas preguntos. Phoenix College Preparatory Academy es una escuela secundariapUblica gratuita y no require ningUn tipo de informaciOn o
documentaci6n de ciudadania o estatus migratorio para inscriber a los estudiantes en a las closes de secundaria. Los estudiantes se inscriben y se base en el
primero de llegar, sera el primero servidolregistrado.
1202 West Thomas Road, OSE105
+ Phoenix, AZ 85013 + Phone 602.285.7998 • Fax 602.285.7697
~
Phoenix
College
Preparatory Academy
1202 West Thomas Road, OSE105 + Phoenix, AZ 85013 + Phone 602.285.7998 +Fax 602.285.7697
Records Request Form
Name and Address of Last School Attended
Nombre y Direcci6n de Ultima Escuela
-------------Name of Student
Date of Birth
Nombre del Estud"'i_an_t_e_ _ _ _ _ _ _ _ _ _ _ _ _ _ Fecha de Nacr,...,nn_,,,-e-nt_o_ _ _ __
Last Date of Attendance
Ultima Fecha de Asistenc""i_a_ _ _ _ _ _ __
Last Grade Attended ___,---Ultimo Grado que Asistieron
Please send the complete official transcript of the above named student. Also include:
1. Date of attendance
2. Withdrawal grades
3. Explanation of marks used in
grading
4. Health and immunization record
5. Withdrawal form
6. AlMS, AZELLA and/or Stanford 10
scores
7. Psychological evaluations
8. Current and/or previous IEP
9. HearingNision Screening
10. Discipline and attendance record
Parent/Guardian Signature _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date/Fecha._ _ _ __
Firma de Padre/Tutor
PLEASE SEND RECORDS TO:
PHOENIX COLLEGE PREPARATORY ACADEMY
1202 West Thomas Road, OSE105
Phoenix, AZ 85013
(602) 285-7998 or
PLEASE FAX RECORDS TO:
(602) 285-7697
ATTN: TIFFANY BARNER
COORDINATOR OF STUDENT SERVICES
THANK YOU FOR YOUR IMMEDIATE RESPONSE
ETHNIC/RACE DATA
INFORMACION ETNICA 0 DE RAZA
In accordance with federal guidance, a two-part questions mus be used to collect data about student race and ethnicity. The first
part of the questions is on ethnicity and the second is on race. The race question can have multiple values. De acuredo con Ia
guiafederal, la pregunta en does partes debe ser usada para colectar informaciOn sabre la raza y la itnica del estudiante. La
pregunta racial puede mUltiple val ores.
Race/Ethnicty Two-Part Question: Anser BOTH questions. Razali:tnica esta preguntas es en does partes:
Conteste LAS DOS preguntas.
The order of the questions is important. The etbnicity questions must be asked frrst, and both questions must be
answered. El arden de las preguntas es importante. La pregunta sabre Ia etnicidad esta en primer Iugar, y ambos
deben ser contestadas.
Part 1: Ethnicity: Is this student Hispanic or Latino? (Choose only one) Parte 1: Etnicidad: Este estudiante es
Hispano o Latino? (Escoja solo una)
o
No, not Hispanic or Latino
No, no Hispano o Latino
o
Yes, Hispanic or Latino (A person of Mexican, Puerto Rico, Cuban, South or Central American, or other
Spanish culture or origin, regardless of race.) Sf, Hispano o Latino (Una persona de origen mexicano,
Puerto Rico, Cuba, centro o sudamericano o de otra cultura u origen espafiol, sin importar !a raza.)
Part 2: Race: What is the student's race? (Regardless of how respondent answered the frrst question, choose one or
more)
Parte 2: Raza: ;,Cual es Ia raza del estudiante? (Independientemente de como contesto Ia primera pregunta, escoja
una a mcis opciones)
o
American Indian or Alaska Native (a person having origins in any of the original peoples of North and
South America, including Central America, and who maintains tribal affiliation or community attachment.)
Indio Americana o Nativo de Alaska (una persona que tiene origenes en cua/quiera de los pueblos
originarios de America del Norte y del Sur, incluyendo America Central, y que mantiene afiliaci6n tribal o
de comunidad.}
o
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.) Asiatica (una persona que tiene origenes en cualquiera de los
pueblos originates del Lejano Oriente, Sudeste de Asia, o el subcontinente indio, incluyendo, par ejemplo,
Camboya, China, India, Japan, Corea, Malasia, Pakistan, las Islas Filipinos, Tai/andia, y Vietnam).
o
Black or African American (a person having origins in any of the black racial groups of Africa.) Negro o
Afro-Americana (una persona que tiene origenes en cualquiera de los negro grupos rae/ales de Africa.}
o
Native Hawaiian or Other Pacific Islander( a person having origins in any of the original peoples of Hawaii,
Guam, Samoa, or other Pacific Islands.) Nativo de Hawai ode otras is/as del Pacifico (una persona con
orfgenes en cuafquiera de los pueblos originarios de Hawai, Guam, Samoa u otras is las del Pacifico.)
White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.)
o
Blanco (Una persona que tiene origenes en cualquiera de los pueblos originates de Europa, los Media
Oriente o AJrica del Norte.)
Parent/Guardian Signature ________ ________ ________ _ Date: _ _ _ _ __
Firma de Padre/Tutor:
1202 West Thomas Road, OS£105
Fecha:
+ Phoenix, AZ 85013 • Phone 602.285.7998 +Fax 602.285.7697
Arizona Department of Education
Arizona Residency Guidelines
9/22/U
INTRODUCTION
Generally, under Arizona law, only Arizona residents are entitled to a free public education. The Arizona
Department of Education ("Departmenf') 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.RS. § l5-823(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
responsibility 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.
VERIFIABLE DOCUMENTATION
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 or physical description of the
property where the student resides (no P. 0. Boxes):
• Valid Arizona driver's license, Arizona identification card
• Valid Arizona motor vehicle registration
• Valid United States passport
• Property deed
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• Mortgage documents
• Property tax bill
• Rental agteement or lease (including Section 8 agteement)
• Utility bill (water, electric, gas, cable, phone)
• Bank or credit card statement
• W -2 wage statement
• Payroll stub
• Certificate of tribal enrollment or other identification issued by a recognized Indian tribe
• Other documentation from a state, tribal, or federal agency (Social Secutity Administration,
Veterans' Administration, Arizona Department ofEconomic 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 iodicating his or her name, the name of the school district, school
site, or charter school in which the student is beiog 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 ofthe person who maintains the residence. A model affidavit is available
for schools at: http:/lwww.azed. gov/fmance/files/20 1111 0/arizona-residency-guidelines. pdf
USE OF AND RETENTION OF DOCUMENTS BY SCHOOLS
School officials must retain a copy of the attestations or affidavits and copies of any supportiog
documentation presented for each student (photocopies acceptable) that school officials believe establish
validity. Documents presented may be different io 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, acconnt numbers, etc.) should be redacted from the
documentation either by the parent/guardian or the school official prior to filing.
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Arizona Department of Education
Arizona Residency Documentation Form
Smdem _______________ _______________
School _ _ _ _ _ _ _ _ _ __
School District or Charter Holder ___________ ___________ __- , P~enULegruGu~ilian
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
As the P~ent!Legal Guardian ofthe Smdent, I attest that I= a resident of the State of Arizona and
submit in support of this attestation a copy of the following document that ilisplays my n=e and
residentiru address or physical description of the property where the smdent 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 creilit c~d statement
_ W-2 wage statement
_Payroll smb
_Certificate oftribru enrollment or other identification issued by a recognized Indian tribe that
contains an Arizona address.
_Documentation from a state, tribal or federru government agency (Sociru Security Administration,
Veteran's Administration, Arizona Dep~ent ofEconomic Security)
_ I = 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.
Signamre of P~ent!Legru Guarilian
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Date
State of Arizona
Mfidavit of Shared Residence
I swear or affirm that I am a resident of the State of Arizona and that the persons listed below reside with
me at my residence, described as follows:
Persons who reside with me:
Location of my residence:
I submit in support of this attestation a copy of the following document that displays my name and current
residence address or physical description of my property:
_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 ofttibal enrollment or other identification issued by a recognized Indian ttibe.
_Documentation from a state, ttibal or federal governrnent agency (Social Secutity Administration,
Veteran's Administration, Arizona Department of Economic Secutity)
Printed Name of Affiant: _ _ _ _ _ _ _ _ _ _ _ __
Signature of A f f i a n t : - - - - - - - - - - - - Acknowledgement
State of Arizona
Couotyof _ _ _ _ _ _ _ _ _ __
The foregoing was acknowledged before me this _ _ day of _ _ _ _ _ _~ 20~
By ________________________
Notary Public
My Commission Expires:
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Departamento de Educaci6n de Arizona
Directrices de Residencia de Arizona
9/22/11
INTRODUCCION
En general, en virtud de Ia ley de Arizona, s6lo los residentes de Aljzona tienen derecho a una educaci6n
publica gratnita. El Departamento de Educaci6n de Arizona ("Departamento") es un mayordomo
designado de educaci6n del Estado de impuestos y es responsable de proporcionar aynda estatal a los
distritos escolares y escuelas de carta para estudiantes que residen en Arizona. En virtud del A.R.S. § 15823(1), un distrito escolar o escuela de Ia Carta no puede incluir a los alunmos no residentes en su nilmero
total de alunmos un distrito escolar o escuela de Ia Carta no puede incluir a los alunmos no residentes en
su nilmero total de alunmos. La residencia de un estudiante se determina par Ia residencia de los padres o
el tutor con quien vive el alunmo. En consecuencia, es responsabilidad de los distritos escolares y
escuelas de Ia carta que reciben el estado ayndan a garantizar que su informacion de Ia residencia de
estudiantes y padres es precisa y verificable. El departamento puede auditar las escuelas para asegnrar que
s6Io los estudiantes residentes de Arizona se informan sabre ayndas estatales. Cua!quier distrito escolar o
escuela de Ia carta que no se puede demostrar Ia exactitud del Estado de residencia del cualquier alunmo
puede estar obligada a devolver las ayndas recibidas para ese alunmo.
DOCUMENTACION COMPROBABLE
A.R.S. § 15-802(B) requiere que los distritos esco!ares y escuelas de carta para obtener y mantener Ia
documentaci6n comprobable de residencia de Arizona a Ia inscripci6n en una escuela publica de Arizona.
Este documento est:\ diseiiado para ayndar a los distritos escolares y escuelas de Ia carta en e!
cumplimiento de los requisites legales del estatuto.
La documentaci6n requerida par A.R.S. § 15-802 debe ser siempre cada vez que un estudiante se
inscribe en un distrito escolar o escuela de Ia carta en este Estado y reafirmados durante el distrito
o el proceso de registro annal de Ia Carta mediante el distrito o el formulario de inscripci6n annal
de Ia Carta. La residencia de Arizona apoyo de documentaci6n debe mantenerse de acuerdo con el
plan de retenci6n de registros de Ia escuela.
En general, estudiantes caera en uno de los dos grupos: (!) aquellos cuyos padres o tutores legales es
capaz de proporcionar Ia documentaci6n que lleva su nombre y direcci6n; y (2) aquellos cuyo padre/tutor
legal no puede documentar su residencia debido a circunstancias incluyendo, pero sin limitarse a, hagar
de Ia familia que multigeneracional atenuantes. Diferente documentaci6n se requiere para cada
circunstancia.
1.
Padre (s) o tutor(s) legal mantiene su residencia: El padre o tutor legal debe completar y
firmar un formulario indicando su nombre, el nombre del distrito esco!ai, sitio de Ia escuela, o charter
school en el cual el estudiante es ser rnatriculado, y uno de los siguientes documentos proporcionan, que
tener el padre o nombre completo del tutor legal y direcci6n residencial o descripci6n fisica de Ia
propiedad donde reside el estudiante (no Apartados postales):
• Documentos de hipoteca
• Proyecto de ley de impuesto sabre Ia propiedad
• Contrato de alquiler o arrendamiento frnanciero (incluido el acuerdo de Ia seccion 8)
• Factura de servicios publicos (agua, electricidad, gas, cable, tel6fono)
• Declaracion bancaria o tarjeta de credito
• Declaracion de salario W -2
• Desprendible de nomina
• Certificado de inscripcion tribal u otra identificacion emitida por una tribu indigena reconocida
• Otra documentacion de una agencia estatal, federal o tribal (administracion de Seguridad Social,
Administracion de veteranos, Arizona departamento de seguridad economica, etc.)
2.
Padre (s) o tutor(s) legal no mantener su residencia: El padre o tutor legal debe completary
firmar un formulario indicando su nombre, el nombre del distrito escolar, sitio de la escuela, o escuela de
Ia carta en Ia que se esta inscrito el estudiante y presentar un signa, declaracion jurada notariada teniendo
el nombre y Ia direccion de Ia persona que mantiene Ia residencia donde vive el estudiante que acredite el
hecho de que el estudiante resida en esa direccion, junto con un documento de Ia lista con vii\etas anterior
teniendo el nombre y la direcci6n de la persona que mantiene la residencia. Un modelo declaraci6njurada
esta disponible para las escuelas en: http://wv.'W.azed.gov/linance/files/2011/l 0/arizona-residencyguidelines.pdf.
USO DEY RETENCION DE DOCUMENTOS POR ESCUELAS Funcionarios de Ia escuela debe
conserve una copia los certificados o declaraciones juradas y capias de cualquier documentaci6n de
apoyo presentada por cada estudiante (fotocopias aceptables) esa escuela funcionarios creen establecer
validez. Documentos presentados pueden ser diferentes en cada circunstancia y Unico a Ia situaci6n de
vida de Ia estudiante. Documentos retenidos por el distrito escolar o escuela de Ia Carta pueden ser
utilizados como un indicios de residencia; Sin embargo, la documentaci6n esta sujeta a auditoria par el
departamento. Informacion de identificacion personal distinto nombre y direccion (SSN, nlimeros de
cuenta, etc.) debe ser redactado de Ia documentacion ya sea por el padre/tutor o par el funcionario de Ia
escuela antes de la presentaci6n.
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Departamento de Educaci6n de Arizona
Formulario de documentaci6n de residencia de Arizona
Estudiante _ _ _ _ _ _ _ _ _ _ _ _ __
Escuela _ _ _ _ _ _ _ _ _ _ __
Distrito Escolar o el titular de Ia C a r t a - - - - - - - - - - - - - - - - - - Padre/tutor Legal _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Como el padre/tutor Legal del alumno, Atestiguan que soy un residente del Estado de Arizona y presentar
en apoyo de esta certificaci6n, una copia del documento siguiente que muestra mi nombre y Ia direcci6n
residencial o descripci6n fisica de Ia propiedad donde reside el estudiante:
_
Licencia de conductor va!ida de Arizona Registro de tarjeta de identificaci6n o vehiculo de motor
Arizona
_
_
_
_
Pasaporte vaJido
Documentos de escritura o hipoteca inmobiliaria
Proyecto de ley de impuesto sobre Ia propiedad
Residencial contrato de arrendamiento o alquiler
_ Agua, electricidad, gas, cable o factura de telefono
_Dec!araci6n bancaria o tarjeta de credito
Declaraci6n de salario W-2
_ Desprendible de nomina
_ Certificado de inscripci6n tribal u otra identificaci6n emitida por una tribu indigena reconocida
Que contiene una direcci6n de Arizona.
_
Documentaci6n de una agencia del gobierno estatal, tribales o federal (Administraci6n de Seguridad
Social, Administraci6n de Veteranos de Guerra, Arizona Departamento de Seguridad Econ6mica)
_Soy actualmente incapaz de proporcionar cualquiera de los documentos anteriores. Por lo tanto, han
proporcionado una dec!araci6njurada original firmado y suscrita por un residente de Arizona que
atestigua que he establecido residencia en Arizona con !a persona que firma la declaraci6n jurada.
Firma del Padre/Tutor Legal
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Pecha
Estado de Arizona
Declaraci6n Jurada de Residencia Compartida
Te lo jura o afirmar que soy un residente del Estado de Arizona, y que las personas que se enumeran a
continuaci6n residan conmigo en mi residenci~ descrito como sigue:
Personas que residen conmigo:
Ubicaci6n de mi residencia:
Presentar en apoyo de esta certificaci6n una copia del documento siguiente que aparece mi nombre y
direcci6n de residencia actual o descripci6n fisica de mi propiedad:
_
Licencia de conductor valida de Arizona, tarjeta de identificaci6n de Arizona o registro de vehiculos
de motor
_ Pasaporte valido
_ Docurnentos de escritura o hipoteca inmobiliaria
_ Proyecto de ley de impuesto sabre Ia propiedad
_ Residencial contrato de arrendamiento o alquiler
_ Agua, electricidad, gas, cable o factura de telefono
_ Declaraci6n bancaria o tarjeta de credito
Declaraci6n de salario W-2
_Desprendible de nomina
_ Certificado de inscripci6n tribal u otra identificaci6n emitida por una tribu indigena reconocida.
_ Documentaci6n de una agencia del gobierno estatal, tribales o federal (administraci6n de Seguridad
Social, administraci6n de veteranos de guerra, departamento de seguridad econ6mica de Arizona)
Nombre Impreso del Declarante: _ _ _ _ _ _ _ _ _ _ _ _ __
Firma del Declarante: _ _ _ _ _ _ _ _ _ _ _ __
Acuse de recibo
Estado de Arizona
Condado de _ _ _ _ _ _ _ _ _ __
dia de _ _ _ _ _ ___o
Lo anterior fue reconocido ante mi
Par _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Notario
Mi Comisi6n expira:
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20~
State of Arizona
Departme nt of Education
Office ofEnglish Language Acquisition Services
Primar y Home Langua ge Other Than English (PHLO TE)
Home Langua ge Survey
(Effective April4, 2011)
These questions are in complianCI' with Arizona Administrative Code, R7-2-306(B)(!), (2)(a-c).
Responses to these statements will be used to determine whether the student will be assessed for
English Language Proficiency.
1. What is the primary language used in the home regardless of the language spoken
by the student? _______ _______ _______ _______ _______ _______ _________
2. What is the language most often spoken by the studen t?----- ------- ------
3. What is the language that the student first acqu ired? ------ ------ -
Student N a m e - - - - - - - - - - - - - - - - Student ill _ _ _ _ _ _ __
I?ate ofBirth _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ SAIS ID _ _ _.-;__ _ _ __
Parent/Guardian Signature ------ ------ ------ ----D ate--- ------ ----District or Chart er---- ------ ------ ------ ------ ------ ------ --School _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~---------
----------------- ---·
·----- ------ ------ -----
Please provide a copy of the Home Language Survey to the ELL Coordlnator!Ma!n Contact on site.
In
SAIS~
please indicate the student's home or primary language.
1535 West Jefferson Street, Phoenix, Arizona 85007 • 602-542-0753 • www.azed.gov/oelas
Estado de Arizona
Departamento de Educaci6n
Servicios de Aprendizaje del Ingles
Idioma Principal en el Bogar excluyendo el inglt~s (PHLOTE)
Encuesta sobre el Idioma en el Bogar
(Efectivo e!4 de abril de 2011)
Preguntas en conformidad con R7-2-306(B)(l), (2)(a-c) del Reglamento de Ia Junta Directiva.
Las respuestas que proporcione a las preguntas siguientes senin usadas para determinar si se
evaluara !a competencia en el idioma ingles de su hijo(a).
l.;.Cual idioma se habia principalmente en su hogar sin considerar el idioma que habla el
estudiante? _____________________ _____________________ _________________
2.i.Cual idioma habla el estudiante con mayor frecuencia? - - - - - - - - - - - 3.i. Cua.J. fue el primer idioma que aprendi6 el estndiante? --------------------- ---Nombre del estudiante ____________ __ Nfun. de identificaci6n _ _ _ _ __
Pecha de nacimiento - - - - ' - - - - - - - - N u m . de SAIS - - - - - - - - - - Firma del padre o tutor _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ P e c h a - - - - - - Distrito o Charter _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Escuela _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
----------------- ----------------- ----------------Please provide a copy of the Home Language Survey to the ELL Coordinator/Main Coniact on site.
In SAIS) please indicate the student's home or primary language.
1535 West Jefferson Street, Phoenix, Arizona 85007 • 602-542-0753 • www.azed.gov/oelas
~
Phoenix
College
Preparatory Academy
1202 West Thomas Road, OSE105
+ Phoenix, AZ
85013
+ Phone 602.285.7998
+Fax ov<.<o;u "'"'
If due to lack of housing, you must live in a shelter, motel, vehicle, or campground, on the
street, in abandoned building or trailers, or doubled-up with relatives or friend, then
according to the McKinney-Vento Act, you are considered homeless.
Your children have the right to:
• Go to school, no matter where you live or how long you have lived there.
• Continue in the school they last attended before you became homeless or the school
they last attended, if that is your choice and is feasible.
• Receive transportation to the school they last attended before your family became
homeless or the school they last attended, if you or a guardian requests such
transportation.
• Attend a school and participate in school programs with children who are not
homeless.
• Enroll in school without giving a permanent address.
• Enroll and attend classes while the school arranges for the transfer of school and
immunization records or any other documents required for enrollment.
• Enroll and attend classes in the school of your choice even while the school and you
seek to resolve a dispute over enrolling your child.
• Receive the same special programs and services, if needed, as provided to all other
children served in these programs.
• Receive transportation t the school and to school programs.
When you move, you should do the following:
• Contact the school local liaison for homeless education (see phone number above) for
help in enrolling your child in a new school or arranging to continue in his or her
former school. (Or, someone at a shelter, social services office, or the school can
direct you to the person you need to contact.)
• Contact the school and provide any information you think will assist the teachers in
helping your child adjust to new circumstances.
• Ask the local liaison for homeless education, the shelter provider, or a social worker
for assistance with clothing and supplies, if needed.
If you need further assistance, call the National Center for Homeless Education at the tollfree Help Line number: 1-800-308-2145 or go online at www.serv.org/nche.
Local Area Contacts: Phoenix College Preparatory Academy, 602-285-7998
State Coordinator: Mattie McVey Lord, 602-542-4963
~
Phoenix
College
Preparatory Academy
1202 West Thomas Road, OSE105
+ Phoenix, AZ 85013 + Phone 602.285.7998 +Fax 602.285.7697
Si debido ala falta de un hagar usted seve obligado a vivir en un albergue, motel, vehiculo, tienda de
campaiia, en la calle al aire libre en edificios abandonados, en caravanas, o compartiendo la misma
habitaci6n con familiares o amigos, usted es considerado como una persona sin hagar de acuerdo con
el Acta de McKinney-Vento.
Sus nifios tienen el derecho de:
• Asistir ala escuela, no importa donde vivan o que tanto tiempo hayan vivido alii.
• Seguir asistiendo a la escuela que asistieron antes de llegar a quedarse sin hagar o a Ia Ultima
escuela que asistieron, si esto es su deseo y es prictico.
• Recibir servicios de transportaci6n ala escuela en donde asistieron antes de llegar a quedarse
sin hagar o ala Ultima escuela que asistieron si ustedes o un guardian de los nifios pide tales
servicios.
• Asistir ala escuela y participar en programas actividades escolares con niiios que tienen
hogar.
•
•
•
•
•
Inscribirse en una escuela sin tener que proveer ninguna direcci6n permanente.
Inscribirse en una escuela y asistir a sus clases mientras que la escuela haga los trfunites
necesarios para obtener los archives escolares, los datos de inmunizaciones, o cualquier otros
documentos necesario para inscribirse.
Inscribirse y asistir aclases en la escuela seleccionada mientras que Ia escuela y ustedes
busquen resolver una disputa sobre Ia escuela seleccionada.
Estar provistos de los mismos programas y servicios especiales, si son necesarios, que se
oftecen a los demas estudiantes que tienen hagar y estan recibiendo estos servicios
Recibir transporte escolar a Ia escuela y a los programas escolares.
Cuando cambien de residencia, deben de hacer lo siguiente:
• Comunicarse con la persona asignada como el oficial de intercomunicaci6n para los niiios y
j6venes sin hogar de la escuela (vea los datos de contacto al pie de esta columna) para ayuda
en inscribir sus niiios en una nueva escuela o para hacer los arreglos necesarios. (Empleados
de los albergues, de los servicios sociales en su comunidad, o de la escuela pueden dirigirles a
la persona con quien se deben comunicar.)
• Comunicarse con Ia escuela y proveer cualquier informaciOn que usted piensa sera Util a los
maestros para ayudar a los nifios hacer los ajustes a sus nuevas circunstancias.
• Pedir al oficial de intercomunicaci6n para los nifios y j6venes sin hogar, los empleados del
albergue, o a los trabajadores sociales asistencia con ropa y Utiles escolares, si es necesario.
Si necesita ayuda adicional, llame al Centro Nacional de Educaci6n para Niiios y J6venes Sin Hogar al
numero de ayuda gratis: 1-800-308-2145 or go online at www.serv.org/ncbe.
Contacto Local: Phoenix College Preparatory Academy, 602-285-7998
Coordinador Estatal: Mattie McVey Lord, 602-542-4963
!
~
~YI
Phoe nix
College
Preparat ory Academy
1202 West Thomas Road, OSE105
+ Phoenix, AZ
85013 + Phone 602285.7998 +Fax 602.285.7697
McKinney-Vento Eligibility Questionnaire
Student N a m e : - - - - - - - - - - - - -
Date of Birth _ _ _ __
Please answer the questions below to help us determine the services your child may be
eligible to receive under the McKinney-Vento Act 42 U.S.C.11435.
1.
Is your current address a temporary living arrangement? DYes
2.
If temporary, is this living arrangement due to loss of housing or economic hardship?
DYes ONo
ONo
If you answered YES to both questions above, please complete the remainder of this form.
If you answered NO, you may stop here.
Where is the student presently living (Check on box).
0
0
0
0
In a motel
In a shelter
With more than one family in a house or apartment
In a place not ordinarily used for sleeping (car, park, etc.)
Name ofParent(s)/Legal Guardian(s): - - - - - - - - - - - - - - - - Address: -----------------~Zip--------Phone Numb er:---- ------Signature of Parent/Legal G u a r d i a n - - - - - - - - - - - - - - - - - - - I certify the above named student qualifies for the McKinney-Vento Act.
Date
McKinney-Vento Liaison Signature
•. <4f':. ... ,
Phoenix
College
Preparatory Academy
1202 West Thomas Road, OSE105
+ Phoenix, AZ 85013 + Phone 602.285.7998 + Fax 602.285.7697
Cuestionario de Elegiblidad- McKinney-Vento
Nombre del Estudiante: ___________ _ Fecha de Nacimiento _ _ _ _ __
Este cuestionario nos ayudar:i determiner sis u hijo(a) califica para recibir servicios bajo el
Acta McKinney-Vento (42 U.S.C.11435). Por favor, conteste las preguntas.
I.
i,Es su domicilio un arreglo de vivienda temporal (de poca duraci6n)?
2.
Si es temporal, i,Es este arreglo de vivienda debido a !a perdida de su vivienda o un
problema econ6mico?
OSi
DNo
OSi
DNo
Si usted contest6 si a estas preguntas, por favor complete el resto de este formulario.
Si usted contest6 NO, a estas preguntas, no siga.
i,D6nde vive el estudiante actualmente? (Seleccione uno)
0
0
0
0
En unmotel
En un Iugar de refugio
Con mas de una familia en una casa o en un apartamento
En un Iugar generalmente no designado para dormir (carro, parque, campamento)
Nombre del P a d r e / T u t o r : - - - - - - - - - - - - - - - - - - - - - - Direcci6n: ___________ ________.Zona Postal _ _ _ _ __
Telefono: - - - - - - - - - Firma del Padre/Tutor _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Yo certifico que el estudiante nombrado en este formulario califica para los programas del
Acta McKinney-Vento.
Fecha
Firma del official autorizado
~
Phoenix
College
Preparatory Academy
Field Trip Permission Slip
Permiso para Paseos Escolares
Location:
Schedule will be sent home before field trip
Localizaci6n: Programaci6n se envianin inicio antes del viaj e de campo
Dates:
Fechas:
The 2013-2014 School Year
El afio escolar 2013-2014
Student Name
Nombre de Estudiante: - - - - - - - - - - - - - - - - - - - Student Address
Domicilio de Estudiante:
------------------ ----------------
Home Telephone
Telefono de Casa: - - - - - - - - - - - - - - - - - - Emergency Telephone
Telefono de emergencia: - - - - - - - - - - - - - - - - - - - Hospital/Doc tor:----------- ---------Parent/Guardian Signature
Date:
Firma de Padre/Tutor: __________ ____Fecha: _____
'Through a shared vision, Phoenix College Preparatory Acad~my is committed to creating and sustaining a community where all/earners will pursue high srandards to succeed in ~"'ifeg!J and career."
~PHOENIX
WcoL
LEGE
Phoenix Collage Preparatory Academy
GO FAR, CLOSE TO HOME.
1202 West Thomas Road, OSE1 05
Phoenix, AZ 85013
(602) 285-7697
phoenixcollege.edu
A Maricopa Community College.
,_._
- .....
""
·········
Phoenix
College
Preparatory Academy
Dear Parents/Guardians of Phoenix College Preparatory Academy Students,
For the safety and security of students, it has been our policy that students are not permitted to
leave the Phoenix College Campus during the lunch hour. Since moving up to the main campus at
Phoenix College, more lunch options are available to our students so the there is really no need to
leave the campus.
If you, as a parent /guardian, of one of our students do not mind that your son/daughter leaves the
campus during lunch, we will require the permission form below, to be signed by you. By signing
the form, you will not hold Phoenix College Preparatory Academy responsible for any injury that
your son/daughter should incur while being off campus during the lunch hour.
Students who leave campus, without your permission or our permission will face disciplinary action
which may include being suspended from school.
We know that you share the concern for student safety and thank you for your cooperation.
Sincerely,
Robert Asadi, Principal
REVOCATION OF PERMISSION
SIGNATURE: _ _ _ _ _ _ _ _ _ DATE: _ _ _ _ TIME: _ _ _ STAFF INITALS:
PHOENIX COLLEGE PREPARATORY ACADEMY
PARENT/GUARDIAN PERMISSION FORM TO ALLOW THEIR SON/DAUGHTER TO LEAVE
PHOENIX COLLEGE CAMPUS DURING THE LUNCH HOUR.
Student's Name
Date _ _ _ _ _ __
I,-:----:-:----:::--:--- ----:----' give my son/daughter.....,...-.,....,..-,--~---,----(parentfguardian's name)
(son/daughter's name)
my permission to leave the campus of Phoenix College during the lunch hour.
By giving my permission, I will not hold Phoenix College Preparatory Academy responsible in the
event of an accident or injury to my son/daughter.
Parent/Guardian, Printed Name
Parent/Guardian, Signed Name
'Through a shared vision. Phoenix College Preparatory Academy is committed to creating and sustaining a community where a/1/aamers will pursue high standards to succeed in college and career."
~PHOENIX
WcoLLEGE
Phoenix College Preparatory Academy
1202 West Thomas Road, OSE105
Phoenix, AZ 85013
(6021285-7697
GO FAR, CLOSE TO HOME.
phoenixcollege.edu
A Maricopa Communrty College.
~
Phoenix
College
P~epa.tatory Academy
Querido padres/guardas de los estudiantes de Phoenix College Preparatory Academy,
Para Ia seguridad de los estudiantes, ha sido nuestra polftica que no permiten a los estudiantes
para salir del campus de Phoenix College durante Ia hora del almuerzo. Desde Ia mudanza al
campus principal en Ia Phoenix College, mas opciones del almuerzo estan disponibles para
nuestros estudiantes asi que no hay realmente necesidad de salir del campus.
Si, como padre /guardian, de uno de nuestros estudiantes no importa que su hijo/hija salga del
campus durante almuerzo, requeriremos el impreso del permiso abajo, para ser firm ados por
ussted. Firmando el impreso, no sostendras Ia Phoenix College Preparatory Academy responsable
de ninguna lesion que su hijo/hija deba incurrir en mientras que esta afuera del campus durante Ia
hora del almuerzo.
Los estudiantes que salen del campus, sin su permiso o nuestro permiso haran frente a Ia acci6n
disciplinaria que puede incluir ser suspendido de escuela.
Sabemos que com partes Ia preocupaci6n por seguridad del estudiante y le agradeces su
cooperaci6n.
Sinceramente,
Robert Asadi, Principal
REVOCACION DE PERMISOS
F I R M A : - - - - - - - - FECHA: _ _ _ _ TIEMPO: _ _ _ PERSONAL INITALS:_ _
PHOENIX COLLEGE PREPARATORY ACADEMY
FORMA DEL PERM ISO DE PADRE/GUARDA PARA PERMITIR QUE SU HIJO/HIJA SALGA DEL
CAMPUS DE LA PHOENIX COLLEGE DURANTE LA HORA DEL ALMUERZO.
Nombre de Estudiante - - - - - - - - - - - - - Fecha _ _ _ _ _ _ __
Yo,---,--.,.----,---,-- -,---,--,---'' le doy mi hijo/hija_ _----:---,--.,-.,....,.-..,-,-- ,---(nombre de padre/guarda)
(nombre de hijo/hija)
mi permiso para dejar el campus de Ia Phoenix College durante Ia hora del almuerzo.
Dando mi permiso, no celebrare Ia Phoenix College Preparatory Academy responsable en case de
accidente o de lesion a mi hijo/hija.
Nombre de Padre/Guarda
Firma de Padre/Guarda
"Through ,1 shared vision, Phoenix College Preparatory Academy is committed to creating and sustaining a community where al/leamers will pursue high standards to succeed in college and career."
&PHOENIX
WcoLLEGE
Phoenix College Preparatory Academy
1202 West Thomas Road. OSE1 05
Phoenix, AZ 85013
(602) 285-7697
GO FAR, CLOSE TO HOME.
phoenixcollege.edu
A Mari(;opa Community College.
.,..._
Phoenix
College
Prepamtory Academy
Consent to Use Photographs without Compensation
Permiso para usar fotografias sin remuneraci6n
I,
, hereby permit Phoenix College Preparatory Academy and
Phoenix College, A Maricopa Community College, free use of photographs taken this day at
_ _ _ _ _ _ _, in which I appear without any claim of present or future compensation of any
kind or restriction of their use under these provsions stated below.
Yo,
, por Ia presente permito que Ia escuela Phoenix College
Preparatory Academy y el colegio Phoenix, que es un colegio comunal del Condado de Maricopa,
usen gratis las fotografias que saquen hoy en
, en las que aparecere, sin reclamar
ahora o en el futuro que se me rmunere de alguna forma y sin restringir de forma alguna que se usen,
conforme las guias que aparecen a continuaci6n.
Student Signature (Firma del estudiante): _ _ _ _ _ _ _ _ _ _ _,Date (Fecha): _ _ _ __
Address (Direcci6n): - - - - - - - - - - - - - - - - - - - - - - - - - - - Telephone (telefono): _ _ _ _ _ _ _ _ _ _ __
If the above individual is under the age of 18 the photo release must also be signed by a
parent/guardian. Si la persona citada es me nor de 18 aiios uno de los padres o tutores tambien debe
firmar el permiso.
Parent/Guardian Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Date: _ _ _ _ __
Firma de Padre/Tutor:
Fecha:
"Through a shared vision Phoenix College Preparatory Acsdemy is committed to creating and sustaining a community wherrt all learners will pursue high standards to succeed in college and career."
~PHOENIX
WcoLLEGE
Phoenix College Preparatory Academy
GO FAR, CLOSE TO HOME.
1202 West Thomas Road. OSE1 05
Phoenix, AZ 85013
(602) 285-7697
phoenixcollege.edu
A Maricopa Community College.
MARICOPA COUNTY COMMUNITY COLLEGE DISTRICT
2411 West 14'h Street, Tempe, AZ
85281-6942
MARICOPA
COMMUNITY
COLLEGES
TRAVEL ASSUMPTION OF RISK & RELEASE OF LIABILIT Y
For Students
Caution: This is a release of legal rights. Read and understand it before signing.
The Maricopa County Community College District is a public educational institution. References to College
("College") include all of the Colleges within the Maricopa County Community College District ("MCCCD"), its
officers, officials, employees, volunteers, students, agents, and assigns.
I
freely choose to participate in the
(henceforth
referred to as the "Program"). In consideration of my participation in this Program, I agree as follows:
SPECIFIC HAZARDS OF TRAVEL: (Specific dangers endemic in this Program's area of travel.)
INSTITUTIO NAL ARRANGEMENTS: I understand that College is not an agent of, and has no responsibility
for, any third party which may provide any services including food, lodging, travel, or other goods or services
associated with the Program. I understand that College is providing these services only as a convenience to
participants and that accordingly, College accepts no responsibility, in whole or in part, for delays, loss, damage
or injury to persons or property whatsoever, caused to me or others prior to departure, while traveling or while
staying in designated lodging. I further understand that College is not responsible for matters that are beyond its
control. I acknowledge that College reserves the right to cancel the trip without penalty or to make any
modifications to the itinerary and/or academic program as deemed necessary by College.
INDEPENDE NT ACTIVITY: I understand that College is not responsible for any loss or damage I may suffer
when I am traveling independently or I am otherwise separated or absent from any College activity. In addition, I
understand that any travel that I do independently on my own before or after the College sponsored Program is
entirely at my own expense and risk.
HEALTH AND SAFETY: I have been advised to consult with a medical doctor with regard to my personal
medical needs. I state that there are no health-related reasons or problems that preclude or restrict my
participation in this Program. I have obtained the required immunizations, if any.
I recognize that College is not obligated to attend to any of my medical or medication needs, and I assume all risk
and responsibility therefore. In case of a medical emergency occurring during my participation in this Program, I
authorize in advance the representative of the College to secure whatever treatment is necessary, including the
administration of an anesthetic and surgery. College may (but is not obligated to) take any actions it considers to
be warranted under the circumstances regarding my health and safety. Such actions do not create a special
relationship between the MCCCD and me. I release the MCCCD, its officers, officials, employees, volunteers,
students, agents and assigns from all liability for any bodily injury or damage I sustain as a result of any medical
care that I receive resulting from my participation in Program, as well as any medical treatment decision or
recommendation made by an employee or agent of the MCCCD. I agree to pay all expenses relating thereto and
release College from any liability for any actions.
TRAVEL CHANGES: If I become separated from the Program group, fail to meet a departure airplane, bus, or
train, or become sick or injured, I will, to a reasonable extent, and at my own expense seek out, contact, and reach
the Program group at its next available destination.
MCMAORROLMTRVL (03/07/11)
PAGE 1 of2
ASSUMPTION OF RISK AND RELEASE OF LIABILITY: Knowing the risks described above, and in
voluntary consideration of being permitted to participate in the Program, I agree to release, indemnify, and defend
College and their officials, officers, employees, agents, volunteers, sponsors, and students from and against any
claim which I, the participant, my parents or legal guardian or any other person may have for any losses, damages
or injuries arising out of or in connection with my participation in this Program.
SIGNATURE: I indicate that by my signature below that I have read the terms and conditions of participation
and agree to abide by them. I have carefully read this Release Form and acknowledge that I understand it. No
representation, statements, or inducements, oral or written, apart from the foregoing written statement, have been
made. This Release Form shall be governed by the laws of the State of Arizona which shall be the forum for any
lawsuits filed under or incident to this Release Form or to the Program. If any portion of this Release Form is
held invalid, the rest of the document shall continue in full force and effect.
Signature of Program Participant
Date
Signature of Parent or Legal Guardian (if student is a minor)
Date
MC~AORROL·TRVL
(03/07/11)
PAGE 2 of2