2017–2018 REQUIRED FORMS PACKETForms Checklist

Grades 3–12

Please review, print (single side only please), complete, and sign the following required forms and return to the school during the Locker and Schedule Pick-Up Open House (see schedule included on page 2).

2017–18 Parent/Student Handbook Acknowledgment

Residency Reaffirmation 2017–18

2017–18 Emergency Contact Form

2017–18 Media Release Form

Computer Use Policy Agreement

Bullying & Sexual Harassment Film Permission (complete grade appropriate form)

CJ Order Form

Locker Agreement (grades 4–12)

Please review, print, complete, and sign the following forms that are applicable to your student and return to the school with the required forms.

Off Campus Lunch Permission (grades 9–12)

Student Parking Policy/Agreement (grades 9–12)

Medicine Administration Authorization

Walk-Off Campus Permission

Please review the following letter and pledge form and return to the school office.

Annual Teacher Fund Pledge Letter

Please notify the BASIS Flagstaff front office as soon as possible if your student will not be present on the first day of school.

version: 0717 | 1706_158 V3

CHECK-IN & OPEN HOUSE SCHEDULE 2017

Monday, August 7

GRADES 5 & 6 CHECK-IN

• Schedules

• Required Forms Return

• Lockers

• CJs

• Bus and Lunch Information

• Booster Information

Grade Time Room 6 8:30 – 9:30 a.m. Gym5 9:30 – 10:30 a.m. Gym

GRADES 3 & 4 OPEN HOUSE

• Group Assignments

• Daily Schedules

• CJs

• Classroom Visit

Grade Time Room 4 10:30 – 11:30 a.m. 3 & 43 1:00 – 2:00 p.m. 1 & 2

Tuesday, August 8

GRADES 7–12 CHECK-IN

• Schedules

• Required Forms Return

• Lockers

• CJs

• Bus and Lunch Information

• Booster Information

Grade Time Room 7 8:30 – 9:30 a.m. Gym8 9:30 – 10:30 a.m. Gym9–12 10:30 – 12:00 p.m. Gym

version: 0717 | 1706_158 V3

PARENT/STUDENT HANDBOOK ACKNOWLEDGMENT2017–2018

Please review the 2017–18 BASIS Charter Schools Parent/Student Handbook at http://basised.com/handbook and sign the form below.

BASIS Flagstaff enforces its policies and procedures without discrimination on the basis of actual or perceived race, color, religion, national origin, sex, age, disability, gender identity or expression, or any other classification protected by law. I will enforce the BASIS Charter Schools Policies and Procedures in order to follow BASIS Flagstaff’s educational goals and fulfill the mission of BASIS Charter Schools.

Corey Hartman August 9, 2017Head of School

I have read, understand, and agree to abide by the Policies and Procedures outlined in the BASIS Charter Schools Parent/Student Handbook.

Student Name (printed)

Student Signature Date

Parent Name (printed)

Parent Signature Date

BASIS Flagstaff|1700 N. Gemini Drive | Flagstaff, AZ 86001 basisflagstaff.org

Version 0717 | 1705_103

RESIDENCY REAFFIRMATION 2017–2018

Student Name: Grade 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

EMERGENCY CONTACT and

MEDICAL INFORMATION

CHILD’S NAME: DATE OF BIRTH: Grade 17/18: Sex: M F

This student has a sibling enrolled □

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

o Pacific Islander o Asian (includes Middle East) Please indicate if student is of Hispanic origin (Please check yes/no) o Yes o 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 1705_103

1703_061 Version: 0317 www.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

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.

I consent to receive Booster Club email updates and announcements to the following email address:

Parent Signature: Date:

1 “BASIS” refers collectively to BASIS Schools, Inc. (BSI), BASIS Educational Group, LLC. (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.

1705_103 Version: 0617

COMPUTER USE POLICY/CONTRACT

Student Name: Grade/Group:

Computers are used at BASIS Curriculum schools 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 and other disciplinary action. Students will be held accountable for their conduct under any applicable BASIS Curriculum School 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 Curriculum school network to gain unauthorized access to any computer system.

• Knowingly performing an act that will interfere with the normal operation of computers, terminals, peripherals, or networks external to the BASIS Curriculum school network.

• Knowingly running or installing on any BASIS Curriculum school computer or network, or giving to another user, a program intended to damage or 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.

• Illegally downloading copyrighted music, videos or other protected media.

• Using electronic mail or other electronic media to harass or bully others.

• Masking the identity of an account or machine.

• Using school computers and/or networks to post or access materials on electronic media that violate the BASIS Curriculum school code of conduct, including but not limited to pornographic material and material promoting violent acts

• 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 Curriculum school computers and networks throughout the year consistent with school rules, policies, and this Agreement. BASIS Schools, Inc., and BASIS Educational Group, LLC will not be held responsible for student's conduct in violation of this agreement.

Student Signature: Date:

Parent Signature: Date:

1705_103 Version: 0617

BULLYING & SEXUAL HARASSMENT PRESENTATION 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 ALL discriminatory practices, including, but not limited to, bullying, cyberbullying, racial discrimination and harassment, and sexual harassment. Bullying, discriminating against, or harassing others on any basis, whether verbal, physical or environmental, is unacceptable and will not be tolerated. A detailed description of BASIS policies regarding discrimination and harassment 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 racial, sexual, and other forms of discrimination and harassment, including how to report instances of bullying, harassment, and discrimination, as well as emphasizing our prohibition on retaliation to ensure students feel safe in reporting inappropriate conduct.

The animated film clips were designed specifically for school age children by the United States Department of Health & Human Services and depict children seeking advice from parents and school officials about how to deal with various peer interactions. The advice given by the adults in the animated film clips provides students with tools for preventing and coping with these situations in real life. A link to the film clip is included here: http://www.stopbullying.gov/kids/webisodes

Please sign below indicating that your child is permitted to view the animated film clip and PowerPoint presentation.

*If you would like to review the PowerPoint presentation, you may request a copy from the front office.

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

¨ YES, I WILL ALLOW MY CHILD TO PARTICIPATE

¨ NO, I WILL NOT ALLOW MY CHILD TO PARTICIPATE

Student Name (please print) Grade/Group

Parent Signature Date

1705_103 Version: 0617

BULLYING & SEXUAL HARASSMENT PRESENTATION Grades 5–8

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 ALL discriminatory practices, including, but not limited to, bullying, cyberbullying, racial discrimination and harassment, and sexual harassment. Bullying, discriminating against, or harassing others on any basis, whether verbal, physical, or environmental, is unacceptable and will not be tolerated. A detailed description of BASIS policies regarding discrimination and harassment 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 cyberbullying, along with a PowerPoint presentation* regarding racial, sexual, and other forms of discrimination and harassment, including how to report instances of bullying, harassment, and discrimination, as well as emphasizing our prohibition on retaliation to ensure students feel safe in reporting inappropriate conduct. 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 how to deal with various peer interactions. The advice given by the adults in the animated film clips provides students with tools for preventing and coping with these situations in real life. A link to the film clip is included here: http://www.stopbullying.gov/cyberbullying/what-is-it/index.html

Please sign below indicating that your child is permitted to participate in the viewing the animated film clips and the PowerPoint presentation. *If you would like to review the PowerPoint presentation, you may request a copy from the front office.

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

¨ 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

.

1705_103 Version: 0617

BULLYING & SEXUAL HARASSMENT FILM PERMISSION Grades 9–12

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 ALL discriminatory practices, including, but not limited to, bullying, cyberbullying, racial discrimination and harassment, and sexual harassment. Bullying, discriminating against, or harassing others on any basis, whether verbal, physical or environmental, is unacceptable and will not be tolerated. A detailed description of BASIS policies regarding discrimination and harassment can be found in the Parent Student Handbook. In keeping with this commitment, we will be showing an approved, educational film to students regarding bullying and harassment, along with a PowerPoint presentation* regarding racial, sexual, and other forms of discrimination and harassment, including how to report instances of bullying, harassment, and discrimination, as well as emphasizing our prohibition on retaliation to ensure students feel save in reporting inappropriate conduct. The film, Confronting Sexual Harassment and Bullying, was designed specifically for high school students, by high school students. It enhances student awareness by depicting various scenarios of harassment in a school environment, and affords them with the tools necessary to identify, prevent and cope with such incidents.

A link to the film is included here: https://www.youtube.com/watch?v=jAMNzJbF6xM

*If you would like to review the PowerPoint presentation, you may request a copy from the front office.

YES, I WILL ALLOW MY CHILD TO WATCH THIS FILM

NO, I WILL NOT ALLOW MY CHILD TO WATCH THIS VIDEO FILM Student Name (Please Print): Grade/Group: Parent Signature: Date:

COMMUNICATION JOURNAL (CJ) The CJ is the primary method of communication between parent(s), teachers, and staff regarding students’ academic performance and/or classroom behavior. We strongly encourage parents to purchase the BASIS Curriculum school Communication Journal through the school for $10.00; however, you are permitted to purchase a similar day planner elsewhere. All students are required to bring their CJs or similar school-approved planners to school every day.

Student Name: _______________________________________

Grade: ___________________

Please check the box if you would like to purchase the 2017–18 BASIS Curriculum School CJ

Payment Options

All Payments to BASIS Curriculum Schools 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/

1705_103 version: 0617

1706_158 Version: 0717

LOCKER AGREEMENT 2017–2018

Grades 4–12 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 Schools 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: _____________________

Payment Options All Payments to BASIS Curriculum Schools 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/

1703_061 | Version: 0617

OFF-CAMPUS LUNCH PERMISSION 9–12th Grade

2017–18

I hereby grant permission for my child, , to leave the school premises ONLY

during his/her scheduled lunch period. Students MUST sign out/in on the Lunch Sign-In/Out Log

located in the School Office.

Students who return late from their lunch period and/or skip the classes following the lunch period,

will be marked as unexcused regardless of having permission to leave for lunch.

Each unexcused absence will be counted as one strike; three strikes and the student will lose his/her

off campus lunch privileges.

I understand that BASIS Schools, Inc. and BASIS.ed are not responsible for my child or his/her

conduct while off school premises during his/her lunch period.

I understand that the school reserves the right to revoke this privilege at any time.

This permission is valid for the 2017–2018 school year only.

Student Name (print): Grade:

Student Signature:

Student Cell #:

Parent Signature Date

Parent Daytime Contact # Parent Cell #

1705_103 1 Version: 0617

STUDENT PARKING AGREEMENT 2017/2018

I, the undersigned BASIS Curriculum school student in grade 9–12, pledge to abide by the following rules and procedures regarding driving and parking in a BASIS Curriculum school parking lot:

1. All students driving to school and parking in a BASIS Curriculum school parking lot must be at least 16 years of age and possess a valid Arizona driver’s license.

2. All students must observe a maximum speed of 5 MPH upon entering the parking lot.

3. The driver and all passengers driven by a BASIS Curriculum school student MUST wear a seatbelt while in the vehicle. This means that under no circumstances will student drivers be allowed to transport passengers in the bed of a pickup truck, Jeep, etc., or in/on any part of a vehicle that is not equipped with a seatbelt.

All students entering into this Agreement must provide the school with the following information:

a. Driver’s license:

b. Insurance Card: ___________________________ (policy #)

c. License Plate number(s) ________________________________

By signing below, I agree that I will follow all the rules set forth above. I understand and agree that if I fail to comply with any of these rules my parking privilege will be revoked.

Student Name: Grade:

Student Signature: Date:

Parent/Guardian Signature: Date:

CONSENT FOR ADMINISTERING MEDICATION

During School Hours 2017–2018

(Please complete one form for each medication to be administered). I understand that the school does not have over the counter medication available to students and my child can only be given the medication that I have provided.

I have provided BASIS Curriculum schools with the following medication and give permission for a BASIS.ed 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 Curriculum schools 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

PERMISSION TO WALK HOME FORM 2017–2018

1703_061 Version: 0617

Dear Parents/Guardians:

This form authorizes a student to sign him/herself out of Late Bird, Student Hours, or other after-school activity and leave campus without an adult.

Students are released from BASIS at or p.m. School policy requires any student who remains on campus for any reason after dismissal time to be signed in to Late Bird, Student Hours, or other after-school activity. Without this signed form on file, students in Late Bird, Students Hours, or other after-school activity will not be allowed to sign out and/or leave campus unless a parent/guardian or other authorized adult is present. Once a student has signed out, he/she may not return to the school campus.

Please complete the following information and return this form to the Front Office.

I give permission for my student (named below) to sign out of Late Bird, Student Hours, or other after-school activity without a parent/guardian or other authorized adult present.

Student’s name: ____________________________________________________ Grade/Element: __________________

Students in grades K–2 MUST be accompanied by an older sibling:

Sibling name, grade, and element:

My child will leave campus and go to the following location(s) (please be specific):

My child is allowed to travel by (check all that apply):

o Biking o Public Transportation

o Walking oOther:

Flagstaff

PERMISSION TO WALK HOME FORM 2017–2018

1703_061 Version: 0617

I expressly acknowledge that there are certain risks of injury, damage, loss, or other harm that may arise from allowing my student(s) to leave campus without an adult, including risks that may not be foreseeable at this moment. Neither BASIS Schools, Inc. (BASIS) or its affiliated entities or agents assumes responsibility for the safety and welfare of the students while they are traveling off campus after school.

As the parent/guardian of my student, I understand and agree that, by signing this form, I am consenting to my student leaving campus without an adult. By signing below, I freely and expressly assume and accept any-and-all risks of injury, damage, loss, and other harm to my student(s) by leaving campus alone. I understand that my student(s) leaving campus alone is voluntary, not required, and that there will be exposure to activities involving risks of illness, serious injury, or even death. Furthermore, I understand and agree that all state and local rules, regulations, and policies, including those regarding appropriate conduct and traffic laws, apply to my student(s) and I expressly assume responsibility for ensuring that my student(s) comply with all applicable rules and laws.

I further agree that, as the parent/guardian of the student(s) identified below, to the fullest extent allowed by law, I will forever release, hold harmless, and indemnify BASIS, BASIS Schools, Inc., BASIS Educational Group, LLC. (d.b.a. BASIS.ed) and any affiliated entities and agents, and their respective officers, directors, employees, volunteers, successors, and assigns, from any-and-all responsibility or liability, including negligence, for injuries, damages, property loss, or other harm, including death, sustained as a result of my student(s) leaving campus unsupervised in accordance with this agreement, including costs, expenses, and attorneys’ fees. I, on my own behalf and as the parent/guardian, agree not to make a claim against or sue any BASIS entity for injuries, damages, property loss, or other harm, including death, relating to my student(s) leaving campus alone.

I have carefully read this document, fully understand its contents, and agree to all the statements, waivers, conditions, and disclaimers set forth herein. I am aware this is a full waiver, indemnification, and release of liability, and a contract between me and BASIS , BSI, and BASIS.ed and I am signing it of my own free will.

Student’s name: Grade/Element __________________

Parent/Guardian name (please print):

Parent/Guardian signature: Date: ________________

Parent/Guardian contact phone number:

Office: Please retain in student file

Flagstaff

BASIS Flagstaff | 1700 N. Gemini Dr, Flagstaff, AZ. 86001 | (928) 774-5502 | BASISflagstaff.orgVERSION 06/17 • 1706_049

Dear parents and friends,

Welcome to the 2017–2018 school year! My goal is to maintain and improve the BASIS Flagstaff culture and the educational programs conducive to our students’ learning. Parents send their children to BASIS Flagstaff because they have an expectation for a rigorous and high-achieving curriculum that prepares students to excel in advanced studies in college and beyond. And prepared they are! On international benchmark exams, the average BASIS Flagstaff student not only outperforms the typical U.S. student, they also out score their peers in countries noted for having the best educational systems in the world. Such preparation cannot be achieved without instruction by our extraordinary teachers and an unwavering commitment to raising the standards of academic success.

Extraordinary TeachersOur priority is the success of your child, and one of the most important factors to that success is the quality of their teachers. They are champions of the BASIS curriculum and are dedicated to every individual student. With a Subject Expert Teacher (SET) and Learning Expert Teacher (LET) in each primary classroom to a majority of lower and upper school teachers holding advanced degrees in their subject, BASIS Flagstaff teachers are passionate and knowledgeable in exceptional ways. We are committed to their advancement and support through the Annual Teacher Fund.

The Annual Teacher FundYour gift to the Annual Teacher Fund is an investment in our teachers, which directly impacts the quality of education in your child’s classroom. Last year, approximately 40% of our parents and friends demonstrated their commitment to BASIS Flagstaff by contributing more than $194,000. These funds allowed us to recruit and retain the highest quality teachers by rewarding them for their effectiveness in the classroom through performance-based bonuses.

Your Family’s SupportAlthough charter schools receive less public funding per student than district schools, we are committed to maintaining our high standards of excellence. Therefore, we ask BASIS families for an annual minimum contribution of $1,500 per student, or a monthly pledge of $150. This gift is only a fraction of the annual cost for a top private school education. We know that every family is different, so we ask you to give as generously as you can. Every gift, no matter the size, has an impact.

To participate, please complete the attached form or visit basisflagstaff.org. All donations are tax deductible to the extent allowed by law and may also qualify for matching gifts with your employer. Thank you for choosing to be a part of our BASIS Flagstaff community!

Sincerely,

Corey HartmanHead of School, BASIS Flagstaff

BASIS Flagstaff | 1700 N. Gemini Dr, Flagstaff, AZ. 86001 | (928) 774-5502 | BASISflagstaff.orgVERSION 06/17 • 1706_049

Payment Method

□ Secure online donationVisit BASISflagstaff.org and click on"Support BASIS." You will receive a taxdeductible receipt upon processingyour donation.

□ Donate by credit card

□ Visa □ Mastercard □ Discover □ AMEX

CC#: ________________________________________

Exp. Date: __________ Security Code: ________

Name on Card: ______________________________

Signature _____________________ Date: ________

□ Donate by check

□ Check enclosed (Payable to BASISFlagstaff)

Amount: $ ______________ Check #: _________

Please send donations to: BASIS Flagstaff, 1700 N. Gemini Dr, Flagstaff, AZ 86001

MatchingGifts

□ My employer has a matching gift programEmployer Name: _____________________________

Employers require matching gifts to be initiated by the donor. Please consult with your employer. Tax ID: 86-0908854.

ThankyouforsupportingourAnnualTeacherFund!

ANNUALTEACHERFUNDGIVINGFORM

Contact/BillingInformation(Pleaseprintallresponses)Name: _____________________________________________________________________________________________Email: ___________________________________________ Phone __________________________________________

Address: _________________________________________________________________________ □ Home □ Work

City: ____________________________________________ State/Zip: _______________________________________

Student’s Name(s) and Grade(s):_____________________________ Relationship to Student _______________

Student’s Name(s) and Grade(s):_____________________________ Relationship to Student _______________

OurFamily’sSupportoftheAnnualTeacherFundforthe2017–18SchoolYearWe ask BASIS families for an annual minimum contribution of $1,500 per student, or a monthly pledge of $150 over the 10 months of the school year. We know that every family is different, so we ask you to give as generously as you can.

My Family's Contribution:

How would you like your name to appear in our acknowledgements? Please print:_____________________________________________

□ I prefer my gift to be anonymous

□ I am unable to support the fund at this time

1 student □ $150

2 students □ $300

3 students □ $450

4 students □ $600

Other □ ___________________

One-timegiftof:

□ $1,500

□ $3,000

□ $4,500

□ $6,000

□ __________________________

Other monthly gift calculation _______ x _______ = _____________Amount Months Total

Payment Start Date ________________ End Date _______________________* Recurring payments will begin in September 2017 and end in June 2018 unless otherwise specified

Monthlygiftof*: