Riverbend Prep Enroll Now

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STUDENT ENROLLMENT FORM

Reminder: only a student’s legal parent/guardian may enroll them in school. Use this checklist to ensure you have submitted all the required documents.

Arizona State Law requires schools to collect the following documents to enroll. Please provide copies of the below documents to the Community Liaison.

Proof of Age and Identity - Any person enrolling a student must provide the school with one of the following:

1.- A copy of the child’s government-issued birth certificate; or

2.- Other reliable proof of identity and age, such as a student’s baptismal certificate, hospital-issued birth certificate, application for a Social Security number, passport, or original school registration records from another public or private school; or

3.-A letter from an authorized representative of an agency having custody of the student.

*Parents/Guardians have 30 days to provide proof of age and identity

Military Student Identifier (included in the enrollment packet)

Arizona Residency Documentation - A person can prove his or her physical residence by completing an Affidavit of Arizona Residency (included in the enrollment packet) and submitting an original or legible copy of one of the following documents that indicate the person’s name and residence address:

1.- Valid Arizona driver’s license, Arizona identification card or motor vehicle registration

2.- Real estate deed, mortgage documents or property tax bill

3.- Residential lease or rental agreement

4.-Water, electric, gas, cable, or phone bill

5.- Bank or credit card statement

6.- State income tax return, W-2 wage statement or payroll stub

7.- Certificate of tribal enrollment or other identification, issued by a recognized American Indian tribe, that contains an Arizona address

8.- Documentation from a state, tribal or federal government agency (Social Security Administration, Veterans Administration, Arizona Department of Economic Security)

The residency documentation received by the school will be maintained in accordance with Arizona Department of Education guidelines and must be updated annually.

Upload Proof of Age and Identity(Required)

Max. file size: 50 MB.

Upload Arizona Residency Documentation(Required)

Max. file size: 50 MB.

Download Release of Student Records (Click here)

If your student transferred from another school, this form gives Riverbend permission to request their educational data. This information is critical for our staff to establish academic plans and ensure your student receives the services they need.

STUDENT REGISTRATION FORMS

Description: The following information is not required to enroll your student at Riverbend Prep. However, providing this information will ultimately benefit your student. We ask that all parents/guardians complete the following information to ensure the best possible educational experience at Riverbend Prep.

GENERAL STUDENT INFORMATION

Name

First Middle Last

Nickname (optional)

Date of Birth

MM slash DD slash YYYY

Gender(Required)

Male

Female

City and Country of Birth(Required)

Primary Phone Number(Required)

Primary Email Address(Required)

Anticipated Grade Level(Required)

Kindergarten

1st

2nd

3rd

4th

5th

6th

7th

8th

Were you referred by a Riverbend Ambassador?(Required)

Yes

Please indicate their name here(Required)

STUDENT EDUCATION INFORMATION

What school district do you reside in?(Required)

What county do you reside in?(Required)

What is the name of the most recent school the student attended and what grade did they attend.(Required)

What is the address of the school above?(Required)

What was the last date the student attended the above school?(Required)

What is the type of school above?(Required)

Public Charter

Public District

Private

Online

Homeschooled

Daycare

Not Applicable

Has your student been expelled from a previous school?(Required)

Yes

STUDENT RESIDENCY INFORMATION

Where the student currently lives

Street Address(Required)

Appt/ Unit number(Required)

City(Required)

Sate(Required)

Zip code(Required)

PARENTS/ GUARDIAN CONTACT INFORMATION

Primary Parent/Guardian Contact (Mailing Address)

Is the mailing Address same as student residence address(Required)

Yes

Name(Required)

First Last

Relationship to Student(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Primary Phone(Required)

Primary Email(Required)

Name of Employer(Required)

Employer phone(Required)

Occupation(Required)

Highest Level of Education Completed

SECONDARY PARENT/GUARDIAN CONTACT

Secondary Parent/Guardian Contact (Mailing Address)

--Is the mailing Address same as student residence address(Required)

Yes

Name(Required)

First Last

Relationship to Student(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Primary Phone(Required)

Primary Email(Required)

Name of Employer(Required)

Employer phone(Required)

Occupation(Required)

Highest Level of Education Completed

Is Emergency Contact?(Required)

Yes

OPTIONAL AUTHORIZED THIRD CONTACT

Name

First Last

Relationship to Student

Address

Street Address City State / Province / Region ZIP / Postal Code

Primary Phone

Primary Email

Name (Employer)

First Last

Employer phone

Occupation

Highest Level of Education Completed

Is Emergency Contact?

Yes

ADDITIONAL EMERGENCY CONTACTS

Name

First Last

Phone

Relationship

Name

First Last

Phone

Relationship

PARENT/GUARDIAN CUSTODY INFORMATION

The child lives with (Select one)(Required)

Both Biological Parents

One biological Parent Only

Legal Guardian

Both Biological Parents Alternating

Name of Legal Parent/Guardian with Custody (1)(Required)

First Last

Telephone Guardian (1)(Required)

Email Guardian (1)(Required)

Name of Legal Parent/Guardian with Custody (2)

First Last

Telephone Guardian (2)(Required)

Email Guardian (2)

Please select one if applicable

A non-custodial parent does not reside locally

A non-custodial parent is legally prohibited from contact (submit legal documentation required)

TECHNOLOGY

Select the technology your child has access to at home(Required)

Laptop/computer

Tablet

Internet

Printer

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT

By filling my name below, I hereby authorize Riverbend Prep. to secure emergency medical treatment for the above-named child while under their supervision.

Name of Child’s Healthcare Provider(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone(Required)

After hours/ Emergency phone(Required)

Preferred Hospital for Emergency Treatment(Required)

Heath Insurance Provider Name(Required)

Heath Insurance Provide Policy Number(Required)

Health or Mental Health Conditions (Please list)(Required)

Allergies (please list)(Required)

Does your child require medicine to be administered at school (select one)(Required)

Yes

provide the medication in the original prescription bottle with the child's name on it. If your child needs to take any over-the-counter medication, you must provide the specific, age-appropriate medication in the original sealed container. All medication must be brought to the office by a parent or guardian and a Consent for Giving Medication at School Form must be completed and signed by the parent/guardian.

Name of Guardian(Required)

First Last

AUTHORIZATION TO PARTICIPATE IN PHYSICAL ACTIVITY

To the best of my knowledge, the above-named child does not have any health problems that would be harmful to him/her while participating in Physical Education or which would require a physical exam. I hereby give permission for the exchange of information regarding the child's medication and medical issues. Be it known that I, the undersigned parent or legal guardian of the student named above, do hereby and grant unto any medical doctor or hospital my consent and authorization to render such aid, treatment, or core to said student as in the judgment of said authority should the student be injured or stricken ill.

Name of Guardian

First Last

ARRIVAL AND DISMISSAL

Students in Family(Required)

Student 1

Name(Required)

First Last

Grade Level(Required)

Student 2

Name(Required)

First Last

Grade Level(Required)

Student 3

Name(Required)

First Last

Grade Level(Required)

Student 4

Name(Required)

First Last

Grade Level(Required)

Student 5

Name(Required)

First Last

Grade Level(Required)

Student 6

Name(Required)

First Last

Grade Level(Required)

Please check the transportation you will utilize for each of the three-time period

Morning (All Days)(Required)

Parent/ Guardian Driver or Carpool

School Bus

Parent/ Guardian Walking

City Bus

Day Care Van

Extended Day Program

Other

Please specify other.(Required)

Afternoon (Full Days)(Required)

Parent/ Guardian Driver or Carpool

School Bus

Parent/ Guardian Walking

City Bus

Day Care Van

Extended Day Program

Other

Please specify other.(Required)

Afternoon (Half Days)(Required)

Parent/ Guardian Driver or Carpool

School Bus

Parent/ Guardian Walking

City Bus

Day Care Van

Extended Day Program

Other

Please specify other.(Required)

Please note: school bus transportation is not guaranteed. Contact the Community Liaison to secure school bus transportation.

Release Approval - My children may be released to the following individuals(Required)

Student 1

Name(Required)

First Last

Relationship(Required)

Phone(Required)

Student 2

Name(Required)

First Last

Relationship(Required)

Phone(Required)

Student 3

Name(Required)

First Last

Relationship(Required)

Phone(Required)

Student 4

Name(Required)

First Last

Relationship(Required)

Phone

Student 5

Name(Required)

First Last

Relationship(Required)

Phone(Required)

Student 6

Name(Required)

First Last

Relationship

Phone

ETHNICITY AND RACE

This information provides valuable data about the community that we serve. This section is optional and is not required for enrollment.(Required)

American or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Hispanic

UntitledWhat is your tribal affiliation(Required)

What country/ region in Asia(Required)

Country/ ethnic group affiliation(Required)

List all race/ ethnic Affiliations(Required)

PARENT LANGUAGE AND SCHOOL REACH

This information ensures our team can always get a hold of parents/guardians and are prepared to communicate in their preferred language.

What language do you prefer to receive school communications in? (Select one)(Required)

English

Spanish

Riverbend Prep. uses School Reach to contact parents with messages regarding student absences, upcoming school events, and other critical information. Please complete the information below regarding how you would like to be contacted.

Primary Phone number(Required)

E-Mail Address(Required)

I understand that it is the parent/ legal guardian's responsibility to update the school office with information changes to ensure the school may contact them in case of emergency.

Name(Required)

First Last

MEDIA RELEASE

We are proud to showcase our awesome community – this form gives the school permission to post pictures, videos, and other content that contains images of your student. It’s great fun for the student who gets to see themselves on Facebook or on the website and helps the school showcase what makes us awesome!

In order for the school to produce materials for both internal and external uses, we need your permission to use photos and/or video images of your child. Please put a check in the appropriate box and sign below to indicate your preference of permission for the following:

Please check only ONE (1)(Required)

Public Display - My child may be photographed/ videotaped, and the photographs/ video may be publicly displayed and/or published. (Social media, web media, news media, marketing, etc.)

School Use Only - If you give your consent to your child's photo appearing in a yearbook and/or being posted within the school building, but do not want his/her picture published to the public, please mark "School Use Only". (Bulletin boards. class wall with photos, awards, yearbook/memory book, etc.)

No Media - If for any reason you object to your child being photographed while he/she is participating in school activities, please mark "No Media". This option excludes all items from options "School Use Only" and "Public Display"

Please Note: There is no payment or any other form of compensation for use of your child's image if a photograph and/or video image of your child is used either internally or externally as explained in the examples above.

Name(Required)

First Last

MILITARY STUDENT IDENTIFIER

Under the Every Student Succeeds Act, school districts have been issued guidelines regarding the collection of a student’s military identifier. Districts are now required to collect and report a student’s Military Identifier which identifies students with a parent or legal guardian who is an active member of the Armed Forces or National Guard.

Check the option that best describes the student’s Military Student Identifier status at any point during the school year. If a parent(s)/legal guardian’s status changes, please notify your child’s school office.(Required)

Student is a dependent of a member of the Active Duty Forces (Army, Navy, Air Force, Marine Corps or Coast Guard)

Student is a dependent of a member of the National Guard (Army National guard or Air National Guard)

Not Applicable

Name of guardian(Required)

First Last

Upload Military Student Identifier (Optional)

Max. file size: 50 MB.

PERMISSION TO RELEASE SCHOOL RECORDS

Release of student records

Name (parent/ guardian)

First Last

as the legal parent/guardian of

Name (student name)

First Last

hereby request my student’s records be sent to Riverbend Prep. Please deliver the below information to the Riverbend Prep. Registrar via electronic mail to: frontoffice@riverbendprep.org

Select

Withdrawal form

Academic records

Health Records

Individual Education Plan or 504 Plan

AZELLA Scores/ELL program information

Discipline information

The student’s records will be kept on file at Riverbend Prep. These records will be subject to the confidentiality rules of the State of Arizona.

Per A.R.S.15-828 Paragraph F. Please send all of the student’s records within 10 (10) days from receipt of this form. Under the provisions of section 99.30 of the Family Educational Rights and Privacy Act (FERPA), this document authorizes the release of all school and health records of the student listed below. A.R.S 15-828 Paragraph F states that no school shall withhold records due to financial debts. Federal law 99.31 states that no parent’s signature is required for educational records to be sent to another educational agency.

STUDENT INFORMATION

Name(Required)

First Middle Last

Date of birth(Required)

MM slash DD slash YYYY

District/State of Previous School(Required)

Name of Previous School:(Required)

School Phone Number(Required)

Name of guardian

First Last

Add signature field for guardian(Required)

SPECIAL EDUCATION PROGRAM HISTORY

Name of student

First Last

Grade Level(Required)

Has the child ever received Special Education services? (Select one)(Required)

Yes

If you circled “No” please skip to the signature line on this page

Does your child have an Individualized Learning Plan (IEP)?

Yes

Does your child have a 504 Plan?

Yes

Please indicate which services your child received

Academic Support

Behavior Support

Speech/ Language

Medical Support

Other

Please specify(Required)

When was the plan last reviewed/ created?

At which school(s)

Signature of Guardian(Required)

Name of Guardian(Required)

First Last

IMMUNIZATION HISTORY

To protect all children against serious vaccine preventable diseases, Arizona school immunization laws require students to receive immunizations before entry to child care and school. The laws and rules governing school immunization requirements are Arizona Revised Statutes §15-871- 874; and Arizona Administrative Code, R9-6-701–708. To comply with this requirement, please submit your child's immunization records to frontoffice@riverbendprep.org

Documentary proof is not required for a pupil to be admitted to school if one of the following occurs:

The parent or guardian of the pupil submits a signed statement to the school administrator stating that the parent or guardian has received information about immunizations provided by the department of health services and understands the risks and benefits of immunizations and the potential risks of non immunization and that due to personal beliefs, the parent or guardian does not consent to the immunization of the pupil.

The school administrator receives written certification that is signed by the parent or guardian and by a physician or a registered nurse practitioner, that states that one or more of the required immunizations may be detrimental to the pupil's health and that indicates the specific nature and probable duration of the medical condition or circumstance that precludes immunization. An exemption is only valid during the duration of the circumstance or condition that precludes immunization.

Please note: Pupils who lack documentary proof of immunization shall not attend school during outbreak periods of communicable immunization-preventable diseases as determined by the department of health services or local health department. The department of health services or local health department shall transmit notice of this determination to the school administrator responsible for the exclusion of the pupils

Signature of Guardian(Required)

Name of Guardian(Required)

First Last

Upload Immunization Proof (Optional)(Required)

Max. file size: 50 MB.

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