DULUTH PUBLIC SCHOOLS REGISTRATION FORM 22-23

DULUTH PUBLIC SCHOOLS REGISTRATION FORM
Parents/Guardians please drop off or email the address verification and birth verification to:

Technology Village

11 E Superior St, Suite 140

Duluth, MN 55802

Monday-Thursday 8a-5p

valarie.wagenbach@isd709.org

kathleen.wilson@isd709.org

Address Verification: Copy of property Taxes or Lease/Rental Agreement

Birth Verfication: Copy of Birth Certificate

Questions please call (218) 336-8756
Name

First Name Middle Name Student Last Name
Birthdate

MonthDay Year
Date
Gender

FemaleMalePrefer not to specify
Entering Grade
Start Date

MonthDay Year
Date
Resident District (if not Duluth Public Schools - ISD709)
If not a resident of ISD709, has an Open Enrollment Agreement been completed and sent to the Assistant Superintendent’s Office?

Yes?No
Last school attended
City
State
Zip
Has your child ever registered under a different name?

YesNo
If Yes - Previous name
ADDITIONAL STUDENT INFORMATION
Country of Birth

USAOther
Date of entry to USA

MonthDay Year
Date
Date of first enrollment in USA school

MonthDay Year
Date
Has this student completed three or more years of school in the USA?

YesNo
The McKinney-Vento Homeless Education Assistance Act and the Duluth Public Schools assures the educational rights for homeless and highly mobile students. Please answer the questions below that best describe your living situation (Check all that apply).

In a shelter (family shelter, domestic violence, youth shelter) or transitional housingOn the streetCampingIn a motel, hotel or weekly rate housingLive with friends or relatives because you cannot find or afford housingIn an abandoned building, a car, park or public spaceLive with friends or relatives because you are an unaccompanied youth
As part of the McKinney-Vento Homeless Education Assistance Act, Minnesota public and charter schools must provide services that remove barriers to enrollment, attendance and educational success of students. Would you like someone to contact you regarding community supports?

YesNo
Student’s parent or sibling is reservist or recent retiree from the armed forces?

YesNo
Student’s parent is or has been on active duty in the past year?

YesNo
Yes: Start date

MonthDay Year
Date
Yes: End date

MonthDay Year
Date
Parent Name
Branch
Does your child receive any services in the following areas (Check all that apply)?

Title 1Gifted/TalentedEnglish Learner (EL)Special Education - Individual Education Plan (IEP)ADA Section 504 PlanOther (specify)
FAMILY INFORMATION - PRIMARY HOUSEHOLD

The primary residence of your students. Student information, mailings and parent portal access will be provided to custodial adults at this address.
Street Address
Apt #
City
State
Zip
Phone Number
Please enter a valid phone number.
Primary Parent/Guardian Information – Parent(s)/Guardian(s) living in primary household with students.
Full Legal Name (Last, First, Middle)
Birthdate

MonthDay Year
Date
Gender

MaleFemale
Relationship to Student
Relationship to Student

Custodial Adult
Parent/Guardian Email Address
example@example.com
Cell Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Full Legal Name (Last, First, Middle)
Birthdate
Gender

MaleFemale
Relationship to Student
Relationship to Student

Custodial Adult
Email Address
example@example.com
Cell Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
K-12 Transportation

Primary Household AddressChild Care AddressParent Provides Transportation
Child care address
Please list all members of the primary household (parent/guardian, adults & children)
Full Legal Name - List Students First
(Last, First, Middle)
Birthdate
(mm/dd/yy)
Gender

MaleFemalePrefer not to answer
Relationship to Student
(sibling, grandparent, aunt, etc.)
School Attending
Grade
Full Legal Name - List Students First
(Last, First, Middle)
Birthdate
(mm/dd/yy)
Gender

MaleFemalePrefer not to answer
Relationship to Student
(sibling, grandparent, aunt, etc.)
School Attending
Grade
Full Legal Name - List Students First
(Last, First, Middle)
Birthdate
(mm/dd/yy)
Gender

MaleFemalePrefer not to answer
Relationship to Student
(sibling, grandparent, aunt, etc.)
School Attending
Grade
Full Legal Name - List Students First
(Last, First, Middle)
Birthdate
(mm/dd/yy)
Gender

MaleFemalePrefer not to answer
Relationship to Student
(sibling, grandparent, aunt, etc.)
School Attending
Grade
Full Legal Name - List Students First
(Last, First, Middle)
Birthdate
(mm/dd/yy)
Gender

MaleFemalePrefer not to answer
Relationship to Student
(sibling, grandparent, aunt, etc.)
School Attending
Grade
Full Legal Name - List Students First
(Last, First, Middle)
Birthdate
(mm/dd/yy)
Gender

MaleFemalePrefer not to answer
Relationship to Student
(sibling, grandparent, aunt, etc.)
School Attending
Grade
Full Legal Name - List Students First
(Last, First, Middle)
Birthdate
(mm/dd/yy)
Gender

MaleFemalePrefer not to answer
Relationship to Student
(sibling, grandparent, aunt, etc.)
School Attending
Grade
Full Legal Name - List Students First
(Last, First, Middle)
Birthdate
(mm/dd/yy)
Gender

MaleFemalePrefer not to answer
Relationship to Student
(sibling, grandparent, aunt, etc.)
School Attending
Grade
SECOND PARENT/GUARDIAN MAILING

Parent/Guardian not living in the primary household with student. By completing this section, you are giving permission to send student information and mailings to the second parent/guardian. A custodial adult will receive parent portal access.
Full Legal Name (Last, First, Middle)
Street Address
City
State
Zip
Birthdate

MonthDay Year
Date
Gender

MaleFemale
Relationship to Student(s)
Custodial Adult
Email Address
example@example.com
Shared primary household

Type option 1
Cell Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Student name(s) pertaining to this second parent/guardian
Shared Primary Household
EMERGENCY INFORMATION

If unable to reach parent or guardian, please call (local contact):
Name
Cell Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Name
Cell Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
In case of serious accident of illmess and I cannot be reached, I authorize the doctor listed below (local contracts) to provide the necessary treatment
Name of Medical Doctor
Phone Number

Area Code Phone Number
Name of Dentist
Phone Number

Area Code Phone Number
In case of an emergency requiring immediate medical attention and school authorities cannot locate me or the above listed physician, I hereby authorize my child to be taken to:

Essentia HealthSt. Luke’sOther
I CERTIFY THE INFORMATION PROVIDED ON THIS FORM IS TRUE, ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
Parent/Guardian Signature

Clear
Date

MonthDay Year
Date
FOR OFFICE USE ONLY
School accepting registration
Date

MonthDay Year
Date
Legal name and birthdate verified by:

Birth CertificateHealth Care ProfessionalHospital Souvenir CertificateLast Year’s Attendance RecordPassportPermanent School RecordOther Scholastic RecordSLC Registry Verification
Legal address verified by:

Property Tax StatementSigned LeasePurchase AgreementStatewide Enrollment Options FormHomeless
School assigned
Student ID
Date

MonthDay Year
Date
Staff initials
FOR ECS OFFICE USE ONLY
Screen Date

MonthDay Year
Date
Screen Time
Student Number
NewPrevious
MARSS ID
Enter Calendar
Enter Access
Enter IC-005
SAC: 41-Screen by District 42-CTC/EPSDT 43-Head Start 44-Private Provider 45-Conscientious Objector (Not screening) Status End Code: 60-No Referral 61-Referral to Spec Ed 62-Referral to Health Care Provider 63-Referral to Spec Ed and Health Care Provider 64-Referral to Early Childhood Program 65-Referral, Parent Declined 66-Rescreen Planned
District Verification of Information:

I hereby verify that the above information is true and correct to the best of my knowledge
Coordinator of Early Childhood Screening Signature

Clear
The Duluth Public Schools does not discriminate on the basis of race, color, creed, national origin, sex, sexual orientation, age, marital status, status with regard to public assistance, religion or disability in its programs and activities. The following person has been designated to handle inquiries regarding non-discrimination policies: Office of the Assistant Superintendent, 215 North First Avenue East, Duluth, MN 55802, Phone: 218-336-8739. For further information please view: www.ISD709.org/district/non-discrimination-notice or call 1-800-421-3481.
Should be Empty:

DULUTH PUBLIC SCHOOLS REGISTRATION FORM

ADDITIONAL STUDENT INFORMATION

FAMILY INFORMATION - PRIMARY HOUSEHOLD

SECOND PARENT/GUARDIAN MAILING

EMERGENCY INFORMATION

FOR OFFICE USE ONLY

FOR ECS OFFICE USE ONLY

District Verification of Information: