Student Enrollment Form

Student Enrollment Form

Complete the enrollment details for the student(s) and parent/guardian contacts. All original PDF questions and options must be preserved.
Student Information
Student 1 Legal Name*
Student 1 Nickname
Student 1 Bus Rider

Yes
Student 1 Household Physical Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Student 1 Temporary Shared Housing / Shelter / Hotel / Campground / Vehicle / Abandoned Building
Student 1 Date of Birth*

MonthDayYear
Date
Student 1 Grade*
Student 1 Gender*
Student 1 Federal Ethnicity and Race

WhiteBlack or African AmericanAsianHispanic or LatinoNative Hawaiian/Other Pacific IslanderOther
Student 2 Legal Name
Student 2 Nickname
Student 2 Bus Rider

Yes
Student 2 Household Physical Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Student 2 Temporary Shared Housing / Shelter / Hotel / Campground / Vehicle / Abandoned Building
Student 2 Date of Birth

MonthDayYear
Date
Student 2 Grade
Student 2 Gender
Student 2 Federal Ethnicity and Race

WhiteBlack or African AmericanAsianHispanic or LatinoNative Hawaiian/Other Pacific IslanderOther
Student 3 Legal Name
Student 3 Nickname
Student 3 Bus Rider

Yes
Student 3 Household Physical Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Student 3 Temporary Shared Housing / Shelter / Hotel / Campground / Vehicle / Abandoned Building
Student 3 Date of Birth

MonthDayYear
Date
Student 3 Grade
Student 3 Gender
Student 3 Federal Ethnicity and Race

WhiteBlack or African AmericanAsianHispanic or LatinoNative Hawaiian/Other Pacific IslanderOther
Student 4 Legal Name
Student 4 Nickname
Student 4 Bus Rider

Yes
Student 4 Household Physical Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Student 4 Temporary Shared Housing / Shelter / Hotel / Campground / Vehicle / Abandoned Building
Student 4 Date of Birth

MonthDayYear
Date
Student 4 Grade
Student 4 Gender
Student 4 Federal Ethnicity and Race

WhiteBlack or African AmericanAsianHispanic or LatinoNative Hawaiian/Other Pacific IslanderOther
Mother Information
Mother Name*

First NameMiddle NameLast Name
Email Address
example@example.com
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Receive School Mailings and Report Cards

Yes
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Father Information
Father Name*
Email Address
example@example.com
Mailing Address
Receive School Mailings and Report Cards

Yes
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Non-residing Contact
Name*
Relationship to Student*
Mailing Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Email Address*
example@example.com
Receive School Mailings and Report Cards

Yes
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contacts
Emergency Contact 1 Name*

First NameLast Name
Emergency Contact 1 Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 1 Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 1 Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2 Name*

First NameLast Name
Emergency Contact 2 Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2 Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2 Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Additional Information
Early Dismissal Instructions
SPED Services (504 or IEP Records)*
Child Custody Restrictions (Court Order)*
Authorization
Parent/Guardian Signature*
Date Signed*

MonthDayYear
Date
Should be Empty:

Student Enrollment Form

Student Information

Mother Information

Father Information

Non-residing Contact

Emergency Contacts

Additional Information

Authorization