BASIS Goodyear, 15800 W. Sherman Street, Goodyear, Arizona 85338 BASISgoodyear.org

BASIS Goodyear Paperwork Checklist Please use this form as a checklist to make sure you will have everything when you come to the

Welcome to Goodyear event. A staff member will sign off in the space provided one each

station has been completed.

MANDATORY STATIONS: The following stations must be attended in order to complete your students’ check-in. The order of

completion does not matter.

First Day Packet Paperwork Station Emergency Contact/Medical Information Form _____________

Media Release Form _____________

Parent/Student School Contract _____________

Computer Use Policy/Contract _____________

Anti-Bullying/Harassment Video Permission Form _____________

Sexual Harassment Video Permission Form (grade specific) _____________

Residency Reaffirmation Form _____________

If your address has changed, please provide a copy of proper documentation

when at this station.

Health Office Agreement Form

Payments/Books Station Science Workbook pick-up (grades 1-5)

Communication Journal pick-up

Lockers Station (Grades 4-8) Locker Agreement Form _____________

Received Lock/Locker _____________

Schedule Station Received Schedule _____________

OPTIONAL STATIONS:

Health Coordinator Station Immunizations _____________

Medication Consent Form _____________

Boosters Station _____________

BASIS EMERGENCY CONTACT and

MEDICAL INFORMATION

CHILD’S NAME: DATE OF BIRTH:

Grade 15/16: Sex: M F

This student has a sibling enrolled □

Student’s race (check only one) White Hispanic American Indian/Alaskan Native Black

Pacific Islander Asian (includes Middle East)

Please indicate if student is of Hispanic origin (Please check yes/no) Yes No

Parent’s/Guardian’s Name: Parent’s/Guardian’s Name :

Resides with: Y N Relation: Resides with: Y N Relation:

Employer: Daytime Phone: Employer: Daytime Phone:

( ) ( )

Position/Occupation: Position/Occupation:

Home Phone Cell Phone Home Phone Cell Phone

( ) ( ) ( ) ( )

Home Address: Home Address:

City, ST ZIP Code: City, ST ZIP Code

Email: Email:

This is a new email address: □ This is a new email address: □

Vehicle Information: Plate #: Vehicle Information: Plate #:

Make: Model: Year: Make: Model: Year:

ALTERNATIVE EMERGENCY CONTACT

Primary Emergency Contact: Secondary Emergency Contact:

Relation: Relation:

Home Phone Work Phone Home Phone Work Phone

([ ]) ([ ]) ([ ]) ([ ])

Cell Phone ( ) Cell Phone ( )

Address Address

City, ST ZIP Code City, ST ZIP Code

In the event that parent(s)/guardian(s) cannot be reached, I give permission for BASIS Schools to release my child to the Primary

and/or Secondary contact listed above.

Parent’s/Guardian’s Signature Date

MEDICAL INFORMATION

Allergies/Special Health Considerations:

Physician’s Name: Insurance Company:

Hospital/Clinic Preference: Policy Number:

I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital

procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and

waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian

can be reached in the case of an emergency.

Parent’s/Guardian’s Signature Date

Version: 0615 BASISschools.org

MEDIA RELEASE FORM

I hereby irrevocably grant to BASIS1 the right to record the image and/or voice and use the artwork

and/or written work of my child on videotape, film, in photographs, digital media, and in any other

form of electronic or print medium and to edit such recording at their discretion.

I further grant BASIS the right to use my child’s image and/or voice with or without their first name on

the internet, in brochures, and in any other medium and hereby consent to such use. I hereby release

BASIS from all claims, damages, demands, costs, expenses, and liabilities whatsoever in connection

with the above.

I understand that I may decline my consent (by checking the correct box below) and still continue to

participate in all BASIS activities without being disadvantaged with respect to those activities.

Student Name: Grade/Group: (please print first and last name)

I agree and accept the above conditions. I do not agree to the above conditions

I agree for yearbook only

Parent Name (please print):

Parent Signature: Date:

BOOSTER CLUB COMMUNICATIONS:

The School Booster Club will periodically send out email updates and announcements about upcoming

events and activities. If you would like to receive periodic email updates and announcements from the

school’s Booster organization please provide your email address in the space provided below.

YES, please send Booster Club email updates and announcements to the following email address:

NO, I do not wish to receive email communications from the School Booster Club.

1 “BASIS” refers collectively to BASIS Schools, Inc. (BSI), BASIS Educational Group, Inc. (BASIS.ed), BDC, A Public Charter

School, Inc. (BDC), BTX Schools Inc. (BTX), BASIS Independent Schools, LLC (BINS), and BASIS Global, LLC. (BG) their

successors, and their assignees.

Version: 0615 BASISschools.org

COMPUTER USE POLICY/CONTRACT

Student Name: Grade/Group:

Computers are used at BASIS as educational aids, for communicating, and as objects of study

themselves. Such open access is a privilege, and requires that individual users act responsibly.

Misuse of computing, networking, or information resources may result in the restriction of

computing privileges. Students may be held accountable for their conduct under any

applicable BASIS policies, procedures or guidelines. Examples of misuse include, but are not

limited to, the following:

• Using a computer account without authorization.

• Obtaining a password for a computer account without the consent of the account owner.

• Using the BASIS network to gain unauthorized access to any computer system.

• Knowingly performing an act which will interfere with the normal operation of computers,

terminals, peripherals, or networks external to the BASIS network.

• Knowingly running or installing on any BASIS computer or network, or giving to another user, a

program intended to damage or to place excessive load on a computer system or network.

• Attempting to circumvent data protection schemes or uncover security loopholes.

• Violating terms of applicable software licensing agreements or copyright laws.

• Downloading copyrighted music or videos.

• Using electronic mail to harass or bully others.

• Masking the identity of an account or machine.

• Posting materials on electronic bulletin boards that violate the BASIS code of conduct.

• Attempting to monitor or tamper with another user's electronic communications, or reading,

copying, changing, or deleting another user's files or software without the explicit agreement

of the owner.

Students may use BASIS computers throughout the year. Please sign the bottom of this form to

indicate parent(s) and student have read the guidelines above and agree to the terms and

conditions of computer usage at BASIS.

Student Signature: Date:

Parent Signature: Date:

Version: 06/15 BASISschools.org

Notice of Non-Discrimination: In accordance with Title VI of the Civil Rights Act of 1964, Title IX of the Education

Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, Title II of the

Americans with Disabilities Act of 1990, the Boy Scouts of America Equal Access Act and applicable state law, BASIS* does

not discriminate on the basis of actual or perceived race, color, religion, national origin, sex, age, disability or any other

classification protected by law in any of its business activities, including its educational programs and activities which

comply fully with the requirements of state and federal law and Title IX. The following person has been designated to handle

inquiries regarding BASIS’ non-discrimination policies: Anastasia Korte, Compliance Manager, BASIS Educational Group, Inc.,

1715 Skyline Drive Suite 121, Tucson, AZ 85716, 520.219.6000.

*As used in this policy, the term "BASIS" refers to: BASIS Schools, Inc., BASIS Educational Group, Inc., BDC, A Public Charter

School, Inc., and BTX Schools, Inc.

BASIS ANTI-BULLYING CONTRACT

2015/2016 I, ______________________________, understand that the BASIS Parent-Student Handbook defines bully-like

behavior as the following:

“Systematic and/or continued unwanted and annoying actions by a person or group, including

threats and demands. This behavior includes but is not limited to verbal, physical, or sexual

harassment.”

Bullying involves aggressive behavior (whether outward or passive) that is repetitive and involves an

imbalance of power to control others or create a hostile environment.

Some examples of bully-like behavior include but are not limited too:

Punching, shoving, and other acts that hurt people physically

Spreading bad rumors about people

Teasing people in a mean way

Getting certain people to "gang up" on others

Sending mean text, email, or instant messages

Posting nasty pictures or messages about others in blogs or on Web sites

Using someone else's user name to spread rumors or lies about someone

Calling people names (like “gay”) or mocking the way people speak

Pinching or otherwise touching people inappropriately

Prank calling people

I understand that the consequences for bullying or harassment include short-term suspension, long-

term suspension, or expulsion.

If I have any doubts about whether my behavior could possibly be interpreted as bully-like, I will see

one of the administrators immediately to ask.

Student Signature: _________________________________ Date: __________________

Parent Signature: __________________________________ Date: __________________

Parent Printed Name: ______________________________________________________

BASISschools.org

Dear BASIS Parents/Guardians,

BASIS School, Inc. (BASIS) is committed to providing a school environment that ensures the

equality, dignity, and respect of every student. BASIS strictly prohibits discriminatory

practices including verbal, physical or environmental harassment. A detailed description of

BASIS’ no-tolerance policy regarding harassment, The Non-Discrimination and Anti-

Harassment Policies Applicable to all BASIS Schools, can be found in the Parent Student

Handbook.

In keeping with this commitment, we will be showing a brief, educational film to students

regarding harassment. The film “What Can We Do? Bias, Bullying, and Bystanders” from

Welcoming Schools, a Project of the Human Rights Campaign Foundation, depicts school

aged children talking about bullying and harassment they have been exposed to. The film

will be followed by active discussions led by teachers to help students understand what

they can do if they or someone they know is being harassed. Active discussions regarding

bullying will occur throughout the year. You can view the video trailer using the link below.

http://www.youtube.com/watch?v=KIa6S-L_xV4

Please sign below indicating that your child is allowed to participate in the viewing of the

film, “What Can We Do? Bias, Bullying, and Bystanders”.

________________________________________________________________________________

□ YES, I WILL ALLOW MY CHILD TO WATCH THIS FILM

□ NO, I WILL NOT ALLOW MY CHILD TO WATCH THIS FILM

Student Name (Please Print): __________________________________Grade/ Group: ___________

Parent Signature: ______________________________________________________________________

BASISschools.org

Grades 1-4

Dear BASIS Parents,

BASIS Schools, Inc. (BASIS) is committed to providing a school environment that ensures the

equality, dignity, and respect of every student. BASIS strictly prohibits discriminatory practices,

including sexual harassment. Sexual harassment, whether verbal, physical or environmental,

is unacceptable and will not be tolerated. A detailed description of BASIS’ no-tolerance

policy regarding sexual harassment, The Non-Discrimination and Anti-Harassment Policies

Applicable to all BASIS Schools, can be found in the Parent Student Handbook.

In keeping with this commitment, we will be showing a brief, educational film clip to students

regarding bullying along with a PowerPoint presentation regarding sexual harassment. The

animated film clips were designed specifically for school age children by the United States

Department of Health & Human Services. The animated film clips depict children seeking

advice from parents and school officials about bullying and harassment. The advice given

by the adults in the animated film clips provides students with tools for preventing and

coping with incidents of harassment in real life.

A link to the film clips is included here: http://www.stopbullying.gov/kids/webisodes

Please sign below indicating that your child is allowed to participate in the viewing the

animated film clips provided by the U.S. Department of Health & Human Services.

--------------------------------------------------------------------------------------------------------------------------

YES, I WILL ALLOW MY CHILD TO WATCH THESE FILM CLIPS

NO, I WILL NOT ALLOW MY CHILD TO WATCH THESE FILM CLIPS

Student Name (please print) Grade/Group

Parent Signature Date

BASISschools.org

Grades 5-8

Dear BASIS Parents,

BASIS School, Inc. (BASIS) is committed to providing a school environment that

ensures the equality, dignity, and respect of every student. BASIS strictly prohibits

discriminatory practices, including sexual harassment. Sexual harassment, whether

verbal, physical or environmental, is unacceptable and will not be tolerated. A

detailed description of BASIS’ no-tolerance policy regarding sexual harassment, The

Non-Discrimination and Anti-Harassment Policies Applicable to all BASIS Schools, can

be found in the Parent Student Handbook.

In keeping with this commitment, we will be showing a brief, educational film clip to

students regarding sexual harassment. The animated film clips were designed

specifically for school age children by the United States Department of Health &

Human Services. The animated film clips depict children seeking advice from

parents and school officials about bullying and harassment. The advice given

by the adults in the animated film clips provides students with tools for

preventing and coping with incidents of harassment in real life.

A link to the film clips is included here:

http://www.stopbullying.gov/cyberbullying/what-is-it/index.html

Please sign below indicating that your child is allowed to participate in the viewing

the animated film clips provided by the U.S. Department of Health & Human

Services.

--------------------------------------------------------------------------------------------------------------------------

YES, I WILL ALLOW MY CHILD TO WATCH THESE FILM CLIPS

NO, I WILL NOT ALLOW MY CHILD TO WATCH THESE FILM CLIPS

Student Name (please print) Grade/Group

Parent Signature Date

BASISschools.org

Kindergarten

Dear BASIS Parents,

BASIS School, Inc. (BASIS) is committed to providing a school environment that

ensures the equality, dignity, and respect of every student. BASIS strictly prohibits

discriminatory practices, including sexual harassment. Sexual harassment, whether

verbal, physical or environmental, is unacceptable and will not be tolerated. A

detailed description of BASIS’ no-tolerance policy regarding sexual harassment, The

Non-Discrimination and Anti-Harassment Policies Applicable to all BASIS Schools, can

be found in the Parent Student Handbook.

In keeping with this commitment, we will be showing a brief, educational film clip to

our kindergarten students regarding playing nice with other students along with a

PowerPoint presentation regarding sexual harassment. The animated film clips were

designed specifically for school age children by the United States Department of

Health & Human Services. The animated film clips depict children seeking advice

from parents and school officials about bullying and harassment. The advice

given by the adults in the animated film clips provides students with tools for

preventing and coping with incidents of harassment in real life.

A link to the film clips is included here: http://www.stopbullying.gov/kids/webisodes

Please sign below indicating that your child is allowed to participate in the viewing

the animated film clips provided by the U.S. Department of

Health & Human Services.

--------------------------------------------------------------------------------------------------------------------------

YES, I WILL ALLOW MY CHILD TO WATCH THESE FILM CLIPS

NO, I WILL NOT ALLOW MY CHILD TO WATCH THESE FILM CLIPS

Student Name (please print) Grade/Group

Parent Signature Date

BASISschools.org

RESIDENCY REAFFIRMATION FORM

2015-2016

Student Name ___________________________________________________________ Grade Level ______________

(please print first and last name)

Please fill out COMPLETELY with the student’s address of residence:

Street

City State _________ Zip

□ Check this box if your student’s address has changed since his/her initial

enrollment (if checked please complete the required Residency Verification Form

available from the school office)

Parent Name (please print) ______________________________________________

Parent Signature _____________________________________________________

Date _______________________________

Version: 0615 BSI Locker Agreement/CJ Form BASISschools.org

Locker Agreement 2015-2016 Students may utilize a locker for storing textbooks and personal items for a non-refundable fee of

$20.00. Each student is required to use only the lock and locker assigned to them. Under no

circumstances should a lock other than the one assigned to the student by the school be placed

on the locker. The student will be charged $5 to replace a lost or stolen lock. BASIS reserves the

right to inspect contents of the locker at any time. The locker must be kept clean and free of

stickers, graffiti, and paint.

Student Name Grade

Parent/Guardian Signature Date

Communication Journal (CJ)

The CJ is the primary method of communication between PARENT, teachers, and staff regarding a

student’s academic performance or classroom behavior. Parents are strongly encouraged to

purchase the BASIS CJ through the School for $10.00 or an equivalent day planner may be

purchased elsewhere. Students must bring the CJ to school every day.

Please check the following box if you would like to purchase the 2015/16 BASIS CJ

Payment Options

All Payments to BASIS are made through SMART for Charters.

Mail Payment: SMART for Charters

PO Box 54228

Los Angeles, CA 90054-0228

Phone Payment: 877-418-1003

Online Payment: http://parent.smartforcharters.com/

CONSENT FOR ADMINISTERING MEDICATION

During School Hours

2015/2016

Complete one form for each medication to be administered.

I have provided BASIS with the following medication and give permission for a BASIS staff member to

administer it to my child. The medication is in the ORIGINAL container and is to be given in the

following manner:

Student Name (print): _______________________________________________ Grade:______________

Name of Medication: ____________________________________________________________________

Prescription I have provided BASIS with a copy of the prescription for this medication

OTC (Over-the-Counter)

Dosage: _______________________________ Maximum Dosage per Day: ______________________

Administer this medication at the specific time(s) listed below.

Time(s): _________________________________________________________________

Administer this medication as needed.

By signing below, I acknowledge that this medication was prescribed by a licensed physician and is approved for use in the United States:

Parent/Guardian Signature: _______________________________________Date:__________________

MEDICATION LOG

Date Time Amount Staff Initials Date Time Amount Staff

Initials

STUDENT NAME: MEDICATION:

Updated: 0615 BASISschools.org

Date Time Amount Staff Initials Date Time Amount Staff

Initials

BASISschools.org

PLEDGE OF ALLEGIANCE POLICY

Pursuant to A.R.S. § 15-506 a school shall set aside a specific time each day for students

who wish to recite the Pledge of Allegiance to the United States flag. In accordance

with this requirement, each BASIS School shall provide the opportunity to recite the

Pledge of Allegiance within the first five minutes of the first period of instruction each

day. The recitation of the Pledge will be facilitated by the teacher for those students

who wish to stand and recite the Pledge. On days where mandatory state testing will

take place the students will be provided the opportunity to recite the Pledge during the

seventh period of the day so as not to interrupt the testing schedule prescribed by the

state.

Note: Also in compliance with A.R.S. § 15-506 (A), each BASIS School has:

Acquired a United States flag that was manufactured in the United States

o that is at least two feet by three feet and is appropriately displayed.

Acquired a legible copy of the Constitution of the United States and the Bill of

Rights that was manufactured in the United States.

Displayed the flags in accordance with title 4 of the United States Code in each

classroom and on or near the outside of the school building during school hours

and at such other times as the school authorities direct.

For grades seven through twelve, placed a legible copy of the Constitution of

the United States and the Bill of Rights adjacent to each classroom flag.