1.Student Information

Student name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Adult #1 /Legal Guardian Name /Main contact *

First Name

Last Name

Phone *

(###)

###

####

Primary residence address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Legal guardian and student residence *

yes

no

Adult #2

First Name

Last Name

Phone

(###)

###

####

Second Household

filled if different than primary

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Other Children (under 21) in household

Please say "none" if no other children in primary/secondary household

First Name

Last Name

Date of birth

MM

DD

YYYY

Name

First Name

Last Name

Date of birth

MM

DD

YYYY

Name

First Name

Last Name

Date of birth

MM

DD

YYYY

Emergency Contacts *

First Name

Last Name

Phone *

(###)

###

####

Emergency Contacts *

First Name

Last Name

Phone *

(###)

###

####

Federal Reporting Part 2 *

Check All responses that apply:

American Indian or Alaska Native (A person having origins in any of the original peoples of North and South America, including Central America, and who maintains a tribal affiliation or community attachment .)

Asian (a person having origins in any of the original peoples of the Far East, Southeast Asian, or the Indian subcontinent, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, Philippine Islands, Thailand, Vietnam.

Black or African American (A person having origins in any of the black racial groups of Africa)

Native Hawaiian or other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands

White (A person having origins in any of the original peoples of Europe, the Middle East or North Africa.)

General Enrollment *

Check ALL that apply

ILITARY-CONNECTED YOUTH Student has an immediate family member, including a parent or siblings, who is currently in the armed Forces either as a reservist or on active duty, or has recently retired from the Armed Forces.

MIGRATORY FAMILY, Family has moved to the school district in the last 36 months for temporary or seasonal agricultural or fishing work

GIFTED PROGRAMMING Student is currently enrolled in a talented and gifted program

EL SERVICES Student has received help learning American English

SPECIAL EDUCATION SERVICES Student has an Individual Education Plan (IEP) in one or more disability categories.

504 PLAN student has a section 504 Accommodation Plan as defined by the Americans with Disability categories.

MCKINNEY-VENTO Address is a temporary living arrangement due to loss of housing or economic hardship

NONE apply

Early Childhood screening *

If enrolling in kindergarten, has your child already completed a pre-school screening?

yes

no