Covert Enrollment Form

Primary Student Contact

(with whom does the student reside?)
Name *

First Name Last Name
Primary Phone Number *

Area Code Phone Number
Additional Phone Number

Area Code Phone Number
Relationship to Student *
Select All That Apply to Primary Head of Household *

Has custody Lives with School Pickup Emergency Contact Receives Mail Can release to
Email *
If you do not have an email address, enter noemail@no.com
Physical Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Secondary Student Contact
Name

First Name Last Name
Primary Phone Number

Area Code Phone Number
Secondary Phone Number

Area Code Phone Number
Relationship to Student
Select All That Apply to Secondary Student Contact

Has custody Lives with School Pickup Emergency Contact Receives Mail Can release to
Email
example@example.com
Physical Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mailing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Emergency Contact #1
Name *

First Name Last Name
Relationship to Student *
Primary Phone Number *

Area Code Phone Number
Secondary Phone Number

Area Code Phone Number
Email
example@example.com
Can release to *

Yes No
Emergency Contact #2
Name

First Name Last Name
Relationship to Student
Primary Phone Number

Area Code Phone Number
Secondary Phone Number

Area Code Phone Number
Email
example@example.com
Can release to

Yes No

Affirmation of Prior Discipline

A willful false statement on this affirmation will result in a report to the appropriate authorities, and may result in disenrollment.
Has the student been convicted of a crime, or are any felony charges pending against the student? *

Yes No
If "Yes," please explain:
Has the student had a long-term suspension (more than 10 days) or expulsion from another school? *

Yes No
If "Yes," please explain:
Has the student withdrawn from a school district in lieu of being charged with conduct that may have resulted in a long-term suspension or expulsion? *

Yes No
If "Yes," please explain:
Has the student been asked to leave or otherwise been unenrolled from a private school? *

Yes No
If "Yes," please explain:

Home Language Survey/Encuestra del Lenguaje del Hogar
Covert Public Schools collects information regarding the language background of each of its students. The information is used to determine who should be provided bilingual and/or English as a Second Language instruction under Title VI of the Civil Rights Act of 1964. Please answer the following questions concerning your child:

El Distrito Escolar Publica de Covert Public Schools esta juntando informacion sobre el lenguaje de cada uno de sus estudiantes. Esta informacion se usara para determinar el numero de ninos a quienes se les debe proveer instruccion bilingue o ingles como un lenguaje segundo segun la ley del Titulo VI del Acta de Derechos Civiles de 1964. Favor de responder a las preguntas siguientes de su hija/hijo:
Student Name/Nombre de su hija/hijo *

First Name Last Name
Date of Birth/Fecha del nacimiento *

Month Day Year
Date
What language did your child learn when he/she first began to talk? Que lenguaje aprendio su hijo/hija cuando el/ella empezo a hablar por primera vez? *
What language does your child use at home most often? Que lenguaje habla mas su hijo/hija en la casa? *
What language do you use most often when speaking with your child? Que lenguaje usa Ud. mas cuando habla con su hijo/hija? *
What language is spoken most often by adults at home? Que lenguaje se habla mas por los adultos en casa? *
Printed name of person completing this form
Signature (This form will be printed in the main office. You must sign the printed hardcopy form when you submit required enrollment documentation.)

Clear
Should be Empty:

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Enrollment Form

New Student Information

Last School Attended

Race/Ethnicity

Student Living Arrangement

Primary Student Contact

Secondary Student Contact

Emergency Contact #1

Emergency Contact #2

Health and Special Needs Information

Affirmation of Prior Discipline

Home Language Survey/Encuestra del Lenguaje del Hogar