Merced River School District Enrollment Form (To be completed by the parent or guardian)

Student's LEGAL Name: (from birth certificate):

 

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. African American or Black (600) (Person having origins in any of the Vietnamese (204) Guamanian (302)White (700) original people of North and South Asian Indian (205) Samoan (303) (Persons having origins in any America (including Central America) Laotian (206) Cambodian (207) Chinese (201) Hmong (208) Other Asian (299)

Student's Birthplace: What month and year did your child first enroll in a U.S. school?

If not born in the U.S., what month/year did your child enter U.S.?

American Indian or Alaskan Native (100)

Tahitian (304) Other Pacific Islander (399)

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 graduate High school graduate

Some college (includes AA degree) College graduate

Graduate school/postgraduate training

What special services has your child received? (Please check all boxes that apply) Special Education: Resource (RSP) Special Day Class (SDC) Gifted (GATE) Medical Health Plan English Language Development 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:

Speech/Language Remedial Reading

504 Accommodation Plan Counseling

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 families/individuals due to economic Unsheltered (car/campsite) hardship, loss, or other reasons) In a sheltered or transitional housing program

Grade (If graduated, not applicable)

ALLERGIES (Check all that apply)None: Animals Drugs Insects Food Bee StingsPlants Other Explain: CURRENT MEDICATION(S) NoYes office and completed. Please list below:

List specific item(s) student is allergic to: Describe allergic reaction and/or treatment:

If medication is needed at school a medication consent form must be picked up from the

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

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 herein 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.