SPED Enrollment Form | Berkeley Unified School District

BUSD Special Education Enrollment Form
Grade your student is currently enrolled in:*
Email Address*
Make sure it's correct. Your completed form will be sent to this email address.
Student's First Name*
Type name as it appears on birth certificate.
Student's Last Name*

Please note: This application will only be used as confirmation of address verification in order to apply for a special education evaluation. If you would like to apply for a public school in BUSD at a later time, you will need to complete the correct enrollment form and re-submit all of the required documents.

STUDENT INFORMATION
Student Name: {childsFirstName} {childsLastName}
Date of Birth*

MonthDayYear
Date
Birthplace*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Age*
Gender*

MaleFemaleNon Binary

Assignment of Students

Students will be admitted to schools in accordance with six established priority categories. A computer assignment system will assign students on a random basis within a priority for each grade level within each school. Priority requirements are as follows:

1st priority: BUSD students currently attending the school (with the exception of transitional kinder) and living within attendance zone

2nd priority: BUSD students currently attending the school (with the exception of transitional kinder) and living outside the attendance zone

3rd priority: Berkeley residents who are siblings of any student currently attending the school on the basis of the first or second priority and who will continue in attendance for the 2023/24 school year

4th priority: Berkeley residents not currently attending the school and living within the attendance zone

5th priority: Berkeley residents not currently attending the school and living outside the attendance zone

6th priority: All non-Berkeley resident students requesting inter-district transfers
Student’s original birth certificate*

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Is this your student's first time enrolling in Transitional Kindergarten or Kindergarten?*

YesNo
Student’s original report card (K-5) or transcript (6-12) for current school year*

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Parent/Legal Guardian original, valid governmental picture identification card*

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I verify that the information on this form is complete and true.
Signature*

Clear
Date*

MonthDayYear
Date

DECLARATION OF RESIDENCY
Do you reside in Berkeley?*

YesNo
Non-Berkeley residents will be considered after all Berkeley residents are placed and if there is space available in the requested grade. Please see more information about Inter-District Permits & Transfers.
I declare that the Berkeley residency information provided below is true and correct.
Parent/Guardian Name:*

First NameLast Name
Email Address:*
example@example.com
Cell Phone:*

Area CodePhone Number
Landline Phone:

Area CodePhone Number
Work Phone:

Area CodePhone Number
Primary Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The following children under the age of 18 reside in the Berkeley household:
Number of children in household:*
Child 1
First Name:*
Last Name:*
Date of Birth:*

MonthDayYear
Date
Current School:*
Current Grade:*
Child 2
Child's Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Current School:*
Current Grade:*
Child 3
Child's Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Current School:*
Current Grade:*
Child 4
Child's Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Current School:*
Current Grade:*
Child 5
Child's Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Current School:*
Current Grade:*
Child 6
Child's Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Current School:*
Current Grade:*
Proof of Berkeley Residency
Documents must be dated within the last 2 months and be imprinted with the parent or legal guardian name and current Berkeley address

Please note we do not accept any Business accounts or DBA

You must submit two proofs from the list below.
- Voter registration for the most recent or upcoming election
- Checking/Savings bank statement
- Credit card statement
- Action letter from Social Services or Government Agency (canot be property)
- Entire utility bill,contract or receipt (PG&E, Landline phone, EBMUD, Internet or Cable)
- Paycheck stub or letter from employer on official company letterhead confirming employment and address on file
- Valid automobile registration
- Valid automobile insurance
- Rental contract/lease with payment reciept
- Current Renters or Homeowners insurance policy
- Current property taxes
- Property deed dated within the year
Proof 1*

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Proof 2*

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I certify that my children and I are residents of the city of Berkeley. Depending on the individual student’s circumstances at times it may be necessary to conduct residency verifications to ascertain the student’s domicile. If residency verification efforts determine that we do not reside in Berkeley, I realize that my child may be dropped from enrollment and returned to his/her district of residence within twenty (20) days.

I understand that I must notify the Admissions Office of any changes in domicile within ten (10) days. If I move within Berkeley, I must also submit the required proofs of Berkeley residency within thirty (30) days to the District’s Admissions Office. If I move out of Berkeley, at that time, I may apply for an interdistrict permit, which, if approved, may allow my child to continue in the Berkeley public schools.

This declaration is made under the penalty of perjury under the laws of the State of California and entered on the date below in Berkeley, Alameda County, California.
Signature*

Clear
Relationship to student(s):*
Date*

MonthDayYear
Should be Empty:

BUSD Special Education Enrollment Form

STUDENT INFORMATION

PARENT/GUARDIAN INFORMATION

Parent 1

Parent 2

DEMOGRAPHIC INFORMATION

EDUCATIONAL BACKGROUND

DECLARATION OF RESIDENCY

The following children under the age of 18 reside in the Berkeley household:

Child 1

Child 2

Child 3

Child 4

Child 5

Child 6

Proof of Berkeley Residency