name: aca c school year 2020- 2021
TRANSCRIPT
Maricopa Institute of Technology (MIT)
Aca demi c School Year
Welcome to M I T!!
The faculty and staff of M I T thank you for choosing us. If you have any
questions about the enrollment process, please call us at:
M I T 602-272-0006
Required Documents
Submit the following
required documents to
complete your student’s
enrollment file.
These documents should be
submitted with the
application:
Proof of Age1. Certified copy of the pupil’s birth
certificate
2. Other reliable proof of the pupil’s
identity and age including the pupil’s
baptismal certificate, an application for
a social security number or original
school registration records and an
affidavit explaining the inability to
provide a copy of the birth certificate
3. A letter from the authorized
representative of an agency having
custody of the pupil pursuant to Title 8,
Chapter 2 certifying that the pupil has
been placed in the custody of the
agency as prescribed by law.
Immunization Records
Proof of Address
Promotion/
Withdrawal from
Previous School
Request for Student
Education Records
Enrollment Form
Complete the attached enrollment application and return it to us as soon as possible.
1. Fill out the Enrollment Application included in this packet. Besure to write legibly to ensure that the registration office isable to process your child’s application with accurateinformation.
2. Please fill out a separate Enrollment Application for eachstudent.
3. Please send or drop off completed forms, along with shotrecords and birth certificate to the MIT front office.
4. Please complete forms online: mitglobalonline.org
How did you hear about MIT?
Internet Parent Liaison
Other
Other Parents
Brochure/Flyer Staff
Transportation is provided to students who live over a mile away from school. Information will be provided at time of registration.
MIT has implemented an automated calling service to notify parents of their child’s attendance and general school information. If you do not wish to receive automated calls, please indicate so on the application.
Automated Calls
Transportation
2020- 2021
Name:
Grade:
Date:
Maricopa Institute of Technology (MIT)
Año Académico
La facultad y el personal de M I T le damos las gracias por escogernos como
su escuela. Si usted tiene alguna pregunta sobre el proceso de registración
estudiantil, favor de llamarnos al:
MIT 602-272-0006
Forma de registración
Favor de completar la forma de registración y devolverla lo más pronto posible.
1. Llene la forma incluida en este paquete. Favor de escribirlegiblemente para asegurar que la oficina de registración puedaprocesar su aplicación con información precisa.
2. Favor de llenar una forma por estudiante.3. Favor de entregar la forma de registración, datos de vacunas y
certificado de nacimiento en la oficina de MIT.4. Favor de llenar la forma de inscripción en el sitio:
mitglobalonline.org
Documentos
Requeridos
Favor de someter los
documentos requeridos
para completar el proceso
de registración estudiantil.
Los siguientes documentos
tendrán que ser sometidos
con su aplicación:
Prueba de Edad1. Copia certificada del certificado de
nacimiento del alumno
2. Otra prueba confiable de la
identidad y edad del alumno, incluido
el certificado de bautismo del alumno,
una solicitud de número de seguro
social o registros de registro escolar
originales y una declaración jurada que
explique la incapacidad de
proporcionar una copia del certificado
de nacimiento
3. Una carta del representante
autorizado de una agencia que tiene la
custodia del alumno de conformidad
con el Título 8, Capítulo 2 que certifica
que el alumno ha sido puesto bajo la
custodia de la agencia según lo
prescrito por la ley.
Expedientes de
Inmunización
Prueba de Domicilio
Promoción/Retiro de
Escuela Anterior
Expedientes del
Estudiante
¿Cómo se enteró de MIT?
Internet Enlace de Padres Otro
Otros Padres Folleto Personal
Transportación se provee para estudiantes que viven en los límites del distrito a más de una
milla de la escuela. Se le proporcionará información al registrar al estudiante en la escuela.
MIT ha implementado un servicio de llamadas automatizadas para notificar a los padres de
la asistencia de sus hijos y información escolar general. Si no desea recibir llamadas
automatizadas, por favor indicarlo en la aplicación.
Transportación
Llamadas automatizadas
2020 - 2021 ¡Bienvenidos a M I T!
Nombre:
Grado:
Fecha:
Reporte de grados actuales del estudiante Student current grades
Reporte del examen estatal AZ Merit Student behavior report
Reporte de comportamiento del estudiante Student attendance report
Reporte de asistencia del estudiante AZ Merit scores
Además, con su solicitud por favor traer la siguiente información:
Additionally, with your application please bring the following:
Todos estos documentos están disponibles para usted en la Oficinade Administración de la escuela de su estudiante.
All of this informaiton can be obtained at your student’s school administration office.
Maricopa Institute of TechnologyStudent Information/Información del Estudiante
Last Name/Apellido First Name/Primer Nombre Middle Name/Segundo Nombre
Grade/Grado
Gender/Genero: Male/Masculino
Female/Femennino
Date of Birth: (mm/dd/yyyy)/
Fecha de Nacimiento:(mm/dd/aaaa)
Fecha de nacimento
Birth Place/Lugar de Nacimiento:
Street Address/Dirección: (Please include Apt. No. if applicable/Por favor incluya el número de departamento si aplica)
City/Ciudad: State/Zip Code/Código Postal: Primary Contact Number/Numero de Contacto Principal:
Is this a temporary living situation due to loss of housing or economic hardship? ____YES ____NO Es su situación de vivienda por perdida de casa o necesidad económica: ____SI ____NO
If you answered yes, you may be eligible for services under the McKinney-Vento Homeless Student Act 42 U.S.C. 11435 Si usted contestó que si, podría ser legible para servicios de la Ley McKinney-Vento para Estudiantes sin Hogar 42 U.S.C.11435
Ethnicity/Etnicidad: We are required to provide yearly information to the Office of Civil Rights and the Office of State Attendance Records. Hispanic/Latino Yes/Si No Estamos obligados a proporcionar información anual a la Oficina de Derechos Civiles y a la Oficina de Registros de Asistencia del Estado.
New Federal Regulations for Race/Ethnic Data/ Nuevas Regulaciones Federales para Raza / Datos Étnicos:
Race/Raza White/Blanco Asian/Asiatico Native American/Alaska Native/ Nativo Americano/Nativo de Alaska
Black/Negro/African American/Africano Americano Native Hawaiian or Other Pacific Islander/Nativo de Hawaii u Otras Islas del Pacifico
Parent/Guardian Name/Nombre de Padre/Guardian: Relationship to Student/Relacion Con el Estudiante
Contact Allowed/Contacto Permitido Educational Rights/Derechos Educativos Has Custody/Tienen la Custodia
Mailings allowed/Correspondencia permitida Release To
Phone/Telefono: Cell #/# de Celular: Work #:/# de Trabajo:
Email Address/ Correo Electronico:
Parent/Guardian Name/Nombre de Padre/Guardian: Relationship to Student/Relacion Con el Estudiante
**Are there Custody Issues?/ No Yes – Please furnish all legal documents ¿Hay problemas de custodia? No Si – Sí, por favor proporcione todos los documentos legales
Name of Last School Attended/Nombre de la ultima escuela que asisitio: City State
Has your child been in Special Education classes? Yes/Si
¿Ha estado su hijo en clases de educación especial? No/No
Does your child have an IEP? Yes/Si
¿Tiene su hijo un IEP? No/No Has this student been in a Bilingual or ESL program?/ ¿Ha estado este estudiante en un programa Bilingüe o ESL?
Yes/Si No/No
Has this student been retained?/ ¿Este estudiante ha sido retenido?
Yes/Si No/No
Has this student been identified as Gifted? Yes/Si No/No
¿Este estudiante ha sido identificado como sobredotado?
Gifted Programs/Programa Sobredotado Yes/Si No/No
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For School Use Only
Start Date Entry Code SAIS # School ID # Teacher
Address Birth Immunization Withdrawal/ Records McKinney- Photo If there are Custodial Issues AZELLA Tested
Verification Certificate ___Yes Report Card Requested Vento Denied were documents provided? ___Yes ____No
__Yes __ No __Yes __No ___No __Yes __No __Yes __No __Yes __No __Yes __No ____Yes ____No Test Date: ______________
Transportation Open IEP 504 System Entry Date Clerk’s Initials Walker/Bike Bus Enrollment Provided Provided
_ Pick Up/p Off Route _____ ___Yes ___Yes ___Yes
___No ___No ___No
Please specify who the student lives with/Por favor especifique con quien vive el estudiante:
Mother/Madre Father/Padre Aunt/Tia Uncle/Tio Guardian/Giardián Grandparents/abuelos Other/otro ___________________________
____ Walker/Bike
____ Pick Up/Drop Off____ Yes
____ No
____ Yes
____ No
____ Yes
____ No
Test Date: ______________ __Yes __ No __Yes __ No __Yes __ No __Yes __No __Yes __ No __Yes __No ____Yes ____No
Start Date Entry Code SAIS # School ID # Teacher
__Yes
__ No
Do you give permission for MIT to send automated calls to the home/cell numbers provided? ¿Da permiso para que MIT envíe llamadas automáticas a los números de teléfono / casa proporcionados? Yes No
Contact Allowed/Contacto Permitido Educational Rights/Derechos Educativos Has Custody/Tienen la Custodia
Mailings allowed/Correspondencia permitida Release To
Phone/Telefono: Cell #/# de Celular: Work #:/# de Trabajo:
Email Address/ Correo Electronico:
Maricopa Institute of Technology
Family Information/Informaciòn de la Familia
1.
In Case of Injury or Sudden Illness, _______________________________ will be called first. I hereby give authority to any hospital or doctor to render immediate aid as might be required at the time for his/her health and safety. It is understood by me that the expense of this service will be accepted by me.
En caso de lesión o enfermedad repentina, se llamará primero a _______________________________. Por la presente doy autoridad a cualquier hospital o médico para que brinde la ayuda inmediata que se requiera en ese momento para su salud y seguridad. Entiendo que el costo de este servicio será aceptado por mí.
Emergency Information/Información de Emergencia
The following people may pick up my child in case of emergency/ Las siguientes personas pueden recoger a mi hijo en caso de emergencia
Name/ Nombre Relationship/ Relación Phone/ Teléfono
Family Information/ Información Familiar
Names of Siblings/ Nombre de Hermanos Relationship/Parentesco Date of Birth/ Fecha de Nacimiento Grade/Grado
What is the primary language of the parent? / ¿Cuál es el idioma principal de los padres?
Language / Idioma:: _________________________________ Will you need an interpreter during Parent/Teacher Conferences, meetings with the principal and/or during Special Education Meetings? / ¿Necesitarás un intérprete durante las conferencias de padres / maestros, reuniones con el director y / o durante las reuniones de educación especial? Yes/Si No/No
Home Language Survey / Encuesta del idioma del hogar
These questions are in compliance with Arizona Administrative Code, R7-2-306 (B)(1), (2)(a-c)/ Estas preguntas están en conformidad con el Código Administrativo de Arizona, R7-2-306 (B) (1), (2) (a-c)
Responses to these statements will be used to determine whether the student will be assessed for English Language Proficiency. / Las respuestas a estas declaraciones se usarán para determinar si el estudiante será evaluado para el dominio del idioma inglés.
What is the primary language used in the home regardless of the language spoken by the student?/ ¿Cuál es el idioma principal utilizado en el hogar, independientemente del idioma que habla el alumno? ___________________________________
What is the language most often spoken by the student?/ ¿Cuál es el idioma que más habla el alumno? ________________________
What is the language that the student first acquired?/ ¿Cuál es el idioma que el alumno adquirió por primera vez? __________________________
Parent/Guardian Signature/ Firma de Padre /Guardián:_________________________________________________Date/Fecha:___________________________
Migrant Survey/Encuesta de Emigrante
Have you moved along with or to join a parent, spouse or guardian within the past 36 months? If no, do not answer the next two questions. / ¿Se ha
mudado junto con un padre, cónyuge o tutor o se ha unido a él en los últimos 36 meses? Si no, no conteste las siguientes dos preguntas.
Yes/Si No/No
Was the primary purpose of the move to obtain (or try to obtain) work that is temporary or seasonal, in agriculture activities including dairy work? /
¿El objetivo principal de la mudanza era obtener (o tratar de obtener) un trabajo temporal o estacional en actividades agrícolas, incluido el trabajo
con productos lácteos? Yes/Sí No/No
Was the agriculture work a primary means of livelihood for you and/or your family? / ¿Fue la agricultura el principal medio de sustento para usted y / o su familia?
Yes/Si No/No
Please check here if MIT DOES NOT have authorization to use your child’s name, phone, photo or video image for school related programs.
Marque aquí si MIT NO tiene autorización para usar el nombre de su hijo, teléfono, foto o imagen de video para programas relacionados con la escuela.
Please check here if you DO NOT wish for your name and information to be given to the school’s Principal Advisory Committee (P.A.C.).
Marque aquí si NO desea que su nombre e información se entreguen al Comité Asesor Principal (P.A.C.) de la escuela.
I understand and certify that all of the above information provided is true and correct.
Entiendo y certifico que toda la información proporcionada anteriormente es verdadera y correcta.
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Parent/Guardian Signature Relationship to Student Date Firma del padre / Guardián Relación con el estudiante Fecha
Maricopa Institute of TechnologyMedical Information/Información Médica
State law requires that a parent/guardian provide consent for minors to receive care and treatment for minor injuries and illnesses. / La ley estatal requiere que un padre / tutor brinde su consentimiento para que los menores reciban atención y tratamiento por lesiones y enfermedades
menores.
Do you give consent to the school to provide care and treatment to your child? / Yes/Si No/No
¿Le da su consentimiento a la escuela para proporcionar atención y tratamiento a su hijo?
Consent Form for Over the Counter Medication Administration / Formulario de consentimiento para la administración de medicamentos sin receta
Dear Parent/Guardian/Estimados Padres/Guardianes:
There are certain procedures that need to be followed should it become necessary for your child to be given over the counter medications during school
hours. Please read and sign below if you wish your child to be given these types of medication at any time during the school year. / Hay ciertos procedimientos
que deben seguirse si es necesario que su hijo reciba medicamentos de venta libre durante el horario escolar. Lea y firme a continuación si desea que a su
hijo se le administren estos tipos de medicamentos en cualquier momento durante el año escolar.
All medications will be given by following manufactures directions, unless written Doctor Orders are given.
No over the counter medication administered by mouth will be given during the last 4 hours of school. / Todos los medicamentos se administrarán siguiendo las instrucciones del fabricante, a menos que se proporcionen órdenes médicas escritas.
No se administrarán medicamentos sin receta administrados por boca durante las últimas 4 horas de la escuela.
I have read and understand the above and I request that MIT personnel assist my child, ____________________________________ by administering
him/her the over the counter medication he/she needs. I give permission for the following types of over the counter medication to be administered to my child: /
He leído y entiendo lo anterior y solicito que el personal de MIT asista a mi hijo, ____________________________________ administrándole el medicamento
de venta libre que necesita. Doy permiso para que los siguientes tipos de medicamentos de venta libre se administren a mi hijo:
Tylenol/Acetaminophen (Generic Tylenol) Pepto-Bismol (Antacids/Antiacido)
Tylenol/ Acetaminofén (Tylenol Genérico)
Topical Ointment (antibiotic/burn ointment, first aid cream) Benadryl, Claritin, Tylenol Sinus (Antihistamines)
Ungüento tópico (ungüento antibiótico / quemado, crema de primeros auxilios) Benadryl, Claritin, Tylenol Sinus (Antihistamínicos
Cough Drops, Sore Throat Lozenges/ Anbesol (Tooth Gel) / Gotas para la tos, pastillas para la garganta dolorida Anbesol (Gel dental)
Cold Medication (Children’s Pedia-Care, Dimetapp) Carmex, Chapstick (for chapped lips)
Medicamentos para el resfriado (Pedia-Care para niños, Dimetap) Carmex, Ungüento Labial (para labios agrietados)
Children’s Motrin (Ibuprofen) Eye drops, eye wash
Motrin para Niños (Ibuprofeno) Gotas para los ojos, lavado de ojos
Parent/Guardian Signature Date
Firma de Padre/Guardián Fecha
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Is your child allergic to food or other substances?/ ¿Es su hijo aergico a comida u otra substancia? Yes/Si No/No If yes, name food or substances to be avoided and procedures to follow if reaction occurs:
En caso afirmativo, nombre los alimentos o sustancias que deben evitarse y los procedimientos a seguir si ocurre la reacción:
Is your child usually susceptible to infection? / ¿Su hijo generalmente es susceptible a la infección? Yes/Si No/No
If so, what precautions need to be taken? / Si es así, ¿qué precauciones se deben tomar?
Is your child subject to convulsions? What should be our procedure if one occurs? / ¿Su hijo está sujeto a convulsiones? ¿Cuál debería ser nuestro
procedimiento si ocurre uno? Yes/Si No/No
Is there any physical condition that we should be aware of and what precautions should be taken (heart trouble, foot problem, hearing
impairments, hernia, etc./ ¿Hay alguna condición física de la que tengamos conocimiento y qué precauciones se deben tomar (problemas
cardíacos, problemas en los pies, problemas de audición, hernias, etc.)? Yes/Si No/No
Does your child have a prescribed Epi-Pen? / ¿Su hijo tiene un Epi-Pen prescrito? Yes/Si No/No
Is your child on any medications at home? If so, please list them: /
¿Su hijo toma algún medicamento en casa? Si es así, nómbralos:
Will your child need to take medication during school hours?/ ¿Su hijo necesitará tomar medicamentos durante el horario escolar? Yes/Si No/No
Yes/Si No/No
Maricopa Institute of Technology
Documentation of Varicella (Chickenpox) Disease or Immunization/ Documentación de la enfermedad o inmunización contra la varicela
Student Name/Nombre del Estudiante: Date of Birth/Fecha de Nacimiento: _________________________
Grade/Grado: Nombre de la escuela:______________________________________________________________ Grado:_____________________________________
Has your child ever had chickenpox? (Please check one answer) ¿Ha tenido su niño(a) la varicela? (Favor de marcar una respuesta)
Yes – Go to #1 No – Go to #2 Don’t Recall – Go to #1
Sì – Vea el # 1 No Vea el #2 No recuerdo – Vea el #1
1. Please answer the following questions: (Please check only one answer per question) Favor de contestar los siguentes preguntas: (Favor de marcar solamente una respuesta por cada pregunta)
A.) Was your child in “face-to-face” contact with other children who had chickenpox? Yes No Don’t Recall ¿Tuvo contacto su niño(a) “cara-a-cara” con otros niños que tenían varicela? Sì No No recuerdo
B.) Did your child have a rash on his/her body? Yes No Don’t Recall ¿Tuvo sarpullido su niño(a) en el cuerpo? Sì No No recuerdo
C.) Did the rash “itch”? Yes No Don’t Recall ¿Le causaba “comezón” el sarpullido? Sì No No recuerdo
D.) Were there blisters present? Yes No Don’t Recall ¿Le salieron ampollas? Sì No No recuerdo
E.) Did “scabs” appear toward the end of the rash? Yes No Don’t Recall
¿Se le hicieron “costras” hacia el final del sarpullido? Sì No No recuerdo
F.) When did your child have chickenpox? _________/_________ ___________
¿Cuándo le dio la varicela a su niño(a)? Month / Year Age (Mes) / (Año) (Edad)
2. If your child has not had chickenpox, has he/she had the chickenpox (Varicella) shot? (Please check one answer) ¿Si no se ha enfermado su niño(a) de la varicela, tiene la vacuna contra la varicela? (Favor de marcar una respuesta) Yes No Don’t Recall Si No No Recuerdo
If you answered YES, please take your child’s immunization record to the school nurse so the date of the vaccine can
be recorded in your child’s health record.
Si su repuesta fue SI, favor de llevar la tarjeta de vacunación de su niño(a) a la enfermera de la escuela para que la fecha de vacunación sea anotada en el
registro de salud de su niño(a).
If you answered NO or DON’T RECALL, please take your child to their doctor or to the local health clinic to get the
chickenpox vaccine, then take their immunization record to the school nurse so the date can be recorded in your
child’s health record.
Si su respuesta fue NO o NO RECUERDO, favor de llevar a su niño(a) al doctor o clínica de salud local para que lo vacunen contra la varicela, luego lleve la
tarjeta de vacunación a la enfermera de la escuela para que la fecha de vacunación sea anotada en el registro de salud de su niño(a).
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I certify that all of the above information provided is true and correct to the best of my knowledge. Yo certifico que toda la información proveída es verdadera y correcta a lo mejor de mi conocimiento.
Parent/Guardian Signature/Firma de Padre/Guardián Date/Fecha
Maricopa Institute of Technology
Student Contract
Student
Name_________________________________________________________________ Last First M.I.
Date of Birth _______/_______/_______ Grade_______ MM DD YYYY
The student contract is between Maricopa Institute of Technology, the parent (s), and the student listed above.
The purpose of this contract is to ensure that the student understands and follows the rules of the school.
Failure to follow the areas identified below by the student may result in the student’s enrollment in the school
being revoked. The decision to revoke the student’s enrollment belongs to the school Headmaster. The
decision of the Headmaster in these matters is final.
Adherence to district and school rules. If your student demonstrates inappropriate behavior, you will be contacted for a conference to discuss your student’s continued enrollment. If the inappropriate behavior continues, your student’s placement will be revoked.
In the event that enrollment is revoked for the school, MIT would provide placement a list of schools in the
surrounding school districts.
___________________________________________ _______________
Student’s Signature (Required) Date
___________________________________________ ________________
Parent/Guardian Signature (Required) Date
___________________________________________ ________________
School/District Administrator Signature (Required) Date
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Maricopa Institute of Technology
Contrato de Estudiante
Nombre del
Estudiante______________________________________________________________ Apellido Nombre Segundo Nombre (Inicial)
Fecha de Nacimiento _______/_______/_______ Grado_______ MM DD YYYY
El contrato de estudiante es entre Maricopa Institute of Technology, el(los) padre(s) y el estudiante mencionado
anteriormente. El propósito de este contrato es asegurar que el estudiante entienda y siga las reglas de la
escuela. El incumplimiento de cualquiera de los aspectos expuestos a continuación por el estudiante puede dar
lugar a que la inscripción del estudiante sea anulada. La decisión de revocar la inscripción de los estudiantes
pertenece al director de la escuela. La decisión del director en estos asuntos es definitiva.
Adhesión a las normas del distrito y la escuela. Si el estudiante demuestra comportamiento inadecuado,
usted será contactado para una conferencia para discutir la continuación de matrícula de su estudiante. Si el comportamiento inadecuado continua, la colocación de su estudiante será revocada.
En caso de que se anule la inscripción de la escuela, MIT le daría una lista de escuelas en distritos alrededor de
MIT.
___________________________________________ _______________
Firma del Estudiante (Se Requiere) Fecha
___________________________________________ ________________
Firma de Padre/Guardián (Se Requiere) Fecha
___________________________________________ ________________
Firma de Administrador de la Escuela/Distrito (Requerido) Fecha
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Arizona Department of Education Arizona Residency Documentation Form
Student School
School District or Charter Holder _____________________________________________
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)
___ 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 Date
#2306606
State of Arizona Affidavit 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 of tribal enrollment or other identification issued by a recognized Indian tribe.
___ Documentation from a state, tribal or federal government agency (Social Security
Administration, Veteran’s Administration, Arizona Department of Economic Security)
Printed Name of Affiant: ______________________________
Signature of Affiant: ______________________________
Acknowledgement
State of Arizona
County of __________________________
The foregoing was acknowledged before me this ____ day of _______________, 20____,
By ____________________________________.
_______________________________
Notary Public
My Commission Expires:
_____________________
#2306606
Arizona Department of Education Office of English Language Acquisition Services
Office of English Language Acquisition Services 1535 West Jefferson Street • Phoenix, Arizona 85007 • (602) 542-0753 • www.azed.gov/oelas
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?
_____________________________________________________________
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.
These HLS questions are in compliance with Arizona Administrative Code (R7-2-306(B)(1),(2)(a-c). (Revised 01-2020)
Student Name________________________________ District Student ID_______________
Date of Birth_________________________________ SSID__________________________
Parent/Guardian Signature______________________________ Date___________________
District or Charter____________________________________________________________
School_____________________________________________________________________
Arizona Department of Education Office of English Language Acquisition Services
Office of English Language Acquisition Services 1535 West Jefferson Street • Phoenix, Arizona 85007 • (602) 542-0753 • www.azed.gov/oelas
Encuesta sobre el Idioma en el Hogar
La escuela utiliza las respuestas a esta Encuesta del idioma del hogar (HLS) para proporcionar los programas y servicios educativos más apropiados para el estudiante. Las respuestas que aparezcan a continuación determinarán si un estudiante tomará la Evaluación de aprendices del idioma inglés de Arizona (AZELLA). Responda a cada una de las tres preguntas con la mayor precisión posible. Si necesita corregir alguna de sus respuestas, esto debe hacerse antes de que el estudiante tome el Examen AZELLA.
1. ¿Qué idioma hablan las personas en el hogar la mayoría del tiempo?
_____________________________________________________________
2. ¿Qué idioma habla el estudiante la mayoría del tiempo?
_____________________________________________________________
3. ¿Qué idioma habló o entendió el estudiante primero?
_____________________________________________________________
Distrito Nombre del estudiante___________________________ Núm. de identificación_____________
Fecha de nacimiento ____________________________ SSID___________________________
Firma del padre o tutor_____________________________________ Fecha________________
Distrito o Charter_______________________________________________________________
Escuela_______________________________________________________________________
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.
Preguntas en conformidad con (R7-2-306(B)(1),(2)(a-c) del Código Administrativo de Arizona. (Revised 01-2020)
STUDENT MEDIA RELEASE One form per student is required
Maricopa Institute of Technology occasionally publishes pictures and videos of students involved in school
activities. Publications may include class newsletters, school newsletters, brochures, flyers, newspaper and, the
Maricopa Institute of Technology website, and / or Facebook page, etc.
Please note:
Any picture or video of a student posted to the website or Facebook page, whether individual, group or
individual, group or team will not include personal information i.e. name grade etc.
Some of these pictures or videos may be action or candid shots taken during participation in an event.
Other pictures or videos may be staged for specific purposes.
Group shots such as class or team pictures may be posted to the website and may be identified by team
or class name, but no individual names will be included.
YES, I hereby consent to authorize Maricopa Institute of Technology to use and produce any and
all photographs and videos taken of this student for Maricopa Institute of Technology without
compensation to me. ALL PROOF and PRINTS will be Maricopa Institute of Technology’s
property solely and completely.
NO, I withhold permission for Maricopa Institute of Technology to use my student’s pictures or video
for any Maricopa Institute of Technology publications as noted above.
Student Name: ____________________________________________________________
Parent/Guardian Printed Name: _______________________________________________
Parent/Guardian Signature: ______________________________ Date: ____________
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Maricopa Institute of Technology (MIT)
A STEM2 Advanced Academics Program
Student Name _____________________________________________________________________________________ Last Name First Name Student SAIS ID #
Parent /Guardian Name______________________________________________________________________________ (Printed name of Parent/Guardian) Driver’s License #
Parent Email Address: _______________________ Cell/Home #______________Work #___________
Understand that the MIT STEM2 Program, including Pre-AP/AP, and Dual Enrollment, has expectations within the accelerated educational
environment that each student must maintain throughout the school year. Students may remain in the MIT STEM Program by maintaining an
individual course average of 70 or higher during each grading cycle in each of the Pre-AP/AP, and Dual credit classes: Math, Science, Social Studies,
and Language Arts. A student earning an average less than 70 may remain in the course only after the growth plan committee’s careful consideration
of the student’s best interest. The MIT Program expectations are:
● Complete assignments: classwork, homework, special projects;
● Bring necessary materials to class;
● Maintain a high degree of organization;
● Participate and remain on-task in class;
● Maintain regular attendance in accordance with school policy;
● Refrain from excessive tardiness in accordance with school policy;
● Adhere to the student code of conduct; and
● Withdrawal from the MIT Program requires a Voluntary Exit Form to be completed and signed.
Students who do not meet the program expectations are placed on the MIT Growth Plan for a minimum of one grading cycle. The growth plan helps
students meet program expectations within an accelerated educational environment, by identifying individual student problems and by providing a
course of action to enable the student to meet academic standards. The growth plan is reviewed each grading cycle that it remains in place, and it
is the documentation used to determine if the student should continue in the advanced level course.
If, after being on a growth plan for a minimum of one grading cycle, the student fails to meet the expectations of the program, a committee comprised
of the Headmaster, Parent/Guardian, the student, and the student’s Teacher(s) will determine the course of action to be taken. The MIT committee
recommendation could result in a recommendation of withdrawal from the MIT Program.
This agreement is in the best interest of the student. We agree to adhere to the program expectations and policies as outline in this agreement.
________________________________________ _____________________________________
Student Signature Date
________________________________________ _____________________________________
Parent/Legal Guardian Signature (Required) Date
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MARICOPA INSTITUTE OF TECHNOLOGY
Release of Student Records
3900 S 55th Avenue, Phoenix, 85043
Phone: 602-272-0006 Fax: 602-272-0309
MIT STEM Magnet 7th -8th Grade MIT STEM 9th -12th Grade
We are requesting the release of the following records for use in providing appropriate educational services and
updating previous reports for the named student below:
Medical: birth certificate, immunization records.
Education: withdrawal form, report cards, official transcripts,
standardized test scores, language survey, gifted results, and
attendance profile.
ELL and Migrant Program Information: program information, test scores, student screening report.
Special Education Program Information: most current IEP, 504 resource provided.
Student: ____________________________________________________ DOB: ____________________________
School: _____________________________________________________ Grade: ___________________________
I hereby authorize (previous school district):
School District: ________________________________________________________________________________
School Name: _________________________________________________________________________________
Address: _____________________________________________________________________________________
City, State, ZIP: ________________________________________________________________________________
Telephone: _________________________________________________ Fax: ______________________________
Parent/Guardian Name: _________________________________________________________________________
Parent/Guardian Signature: _________________________________________________ Date: ________________
For Official Use Only 1st Request: ______________ 2nd Request: _________________ 3rd Request: _________________
Records Received Date: ______________ No Previous Records Requested By: ______________ Date: ____________
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