Race/Ethnicity Questionnaire (NS)(4)

Date

Student's Name*

First NameLast Name

Grade*

Is this student Hispanic/Latino?*

No, not Hispanic/LatinoYes, Hispanic/Latino A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

The above part of the question is about ethnicity, not race. No matter what you selected in Part A above, please provide an answer to Part B by marking one or more boxes below to indicate what you consider your child's race to be.

Which of the following groups describe the student's race? (Chose one or more)*

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 tribal affiliation or community attachment.Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent (for example, Cambodia, China, India, Indonesia, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and 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, Tonga, Samoa, Fiji, New Zealand and the Marshalls or other Pacific Islands.White people is a racial classification specifier, used mostly and often exclusively for people of European descent; depending on context, nationality, and point of view. The term has at times been expanded to encompass persons of Middle Eastern and North African

Parent's Name*

First NameLast Name

Signature*