Merced River School District Online Enrollment Form

Merced River School District Enrollment Form (To be completed by the parent or guardian)
Student I.D. No.
SSID No
Anticipated Start Date

MonthDayYear
Date
Student's LEGAL Name: (from birth certificate)
Name*

First NameMiddle NameLast NameSuffix
Date of Birth: Mo/Day/Year*
Mother/Guardian

Mother's/Guardian's First NameLast Name
Phone Number
Please enter a valid phone number.
Father/Guardian

Father's/Guardian's First NameLast Name
Phone Number
Please enter a valid phone number.
Mailing Address *

Mailing Address

Street Address Line 2

CityState

Zip
Residence Address (if different)

Residence Address (IF DIFFERENT)

Street Address Line 2

CityState

Zip
Name of Last School
City/State
Phone Number
Last Day of Attendance
Student's Birthplace: City/State/Country*
If not born in the U.S., what month/year did your child enter U.S.?
Mo.
Year
What month and year did your child first enroll in a U.S. school?
Mo.
Year
In a California School?
Mo.
Year
ETHNICITY: Mark the ethnicity with which the student most closely identifies: (Please check one)*

Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race)Not Hispanic or Latino
WHAT IS YOUR CHILD'S RACE (Please check up to five racial categories) The above part of the question is about ethnicity, not race. No matter what you selected above, please continue to answer the following by marking one or more boxes to indicate what you consider your race to be.*

American Indian or Alaskan Native (Person having origins in any of the original people of North and South America, including Central America)ChineseJapaneseKoreanVietnameseAsian IndianLaotianCambodianHmongOther AsianHawaiianGuamanianSamoanTahitianOther Pacific IslanderAfrican American or BlackWhite (Persons having origins in any of the original peoples of Europe, North Africa, or the Middle East)
Which language did your son/daughter learn when he/she first began to talk?
What language does your son/daughter most frequently use at home?
What language do you use most frequently to speak to your son/daughter?
Name the language most often spoken by the adults at home:
PARENT EDUCATION LEVEL: Check the response that describes the highest education level of parent/guardian(s):

Not a high school graduateHigh school graduateSome college (includes AA degree)College graduateGraduate school/postgraduate training
What special services has your child received? (Please check all boxes that apply) Special Education:

Resource (RSP)Special Day ClassSpeech/Language504 Accommodation PlanGifted (GATE)Remedial MathRemedial ReadingCounselingMedical Health PlanEnglish Language DevelopmentOther
Has the student been expelled or is the student in the process of being expelled from any school?

YesNo
If yes: Name of school
Location:
Date:

MonthDayYear
Date
RESIDENCE where is your child/family currently living? (Federally mandated by NCLB: Please check appropriate box)*

In a single family permanent residence (house, apartment, condo, mobile home)Doubled-up (sharing housing with other familes/individuals due to economic hardship, loss, or other reasons)In a sheltered or transitional housing programIn a motel/hotelUnsheltered (car/campsite)Other
OTHER CHILDREN IN THE FAMILY:
First / Last Name
Relationship
Lives at home?

YesNo
School / Grade
First / Last Name
Relationship
Lives at home?

YesNo
School / Grade
First / Last Name
Relationship
Lives at home?

YesNo
School / Grade
OTHER ADULTS IN THE HOME:
First / Last Name
Relationship
First / Last Name
Relationship
ALLERGIES (Check all that apply)

NoneAnimalsInsectsBee StingsDrugsFoodsPlantsOther
List specific item(s) student is allergic to
Describe allergic reaction and/or treatment
Explain
CURRENT MEDICATION(S)

NoYesEpi-Pen
If medication is needed at school a medication consent form must be picked up from the office and completed. Please list below:
Name of Medication(s)
Dosage
Time Taken
Purpose
Name of Medication(s)
Dosage
Time Taken
Purpose
MEDIA PERMISSION
I/We give permission for my/our student to be observed, interviewed, photographed and/or filmed when a representative of the media have been permitted by the Principal or designee to be on campus.

YesNo
EMERGENCY MEDICAL AUTHORIZATION
I am/we are the parent/guardian of the above named student. In case I am/we are unable to be reached during any emergency, I/we hereby authorize a representative of the school, pursuant to the provisions of Family Code Section 6910, to act as any agent to consent to the giving of any and all medical, dental, hospital or surgical care to the above named student.

I/We have reviewed this two page document and to the best of my/our knowledge, the Information contained hereln Is true and complete. The undersigned declares under penalty of perjury that they are the parents or legal guardians of the above-named student and grant the above authorizations.
Date

MonthDayYear
Date
Signature of Parent/Guardian

Clear
Should be Empty:

OTHER CHILDREN IN THE FAMILY:

OTHER ADULTS IN THE HOME:

MEDIA PERMISSION

EMERGENCY MEDICAL AUTHORIZATION