ENROLLMENT
F ORM
Office
S taff
O nly
If
E nrolled
A FTER
F all
C ount
D ay:
Today’s
D ate:
Student
S tart/Enrollment
D ate:
☐ Signed
&
d ated
E nrollment
F orm
School
N ame:
Grade
E ntering:
Bus
R oute:
☐ Proof
o f
R esidency
a ttached
Student
N umber:
Teacher
/
C ounselor:
Homeroom:
☐ Complete
S chedule
UIC:
Proof
o f
R esidency
O btained:
☐ Yes
☐ No
☐ Attendance
V alidated
New
t o
D PS:
☐ Yes
☐ No
I f
Y ES:
I mmunizations:
☐ Transcript:
☐
R eport
C ard:
☐
☐ Document
c opies
t o
P PM
v ia
A .S.
Basis
f or
E nrollment:
_ ________
If
n ot
c urrently
l iving
i n
D etroit
P ublic
S chool
b oundary:
W indow
f or
O ,
X
c loses
t he
F riday
o f
t he
1
st
w eek
o f
t he
s tart
o f
s chool.
W hat
i s
t he
D istrict
o f
R esidence?
_ ______________________________________
Household
I nformation
Student’s
L ast
N ame
Student’s
F irst
N ame
Student’s
M iddle
N ame
Suffix
( Jr.,
I II,
e tc.)
Date
o f
B irth
Gender:
Home
P hone
Cell
P hone
Email
A ddress
/
/
☐ Male
☐ Female
Physical
A ddress
( where
s tudent
r esides)
Mailing
A ddress
( If
d ifferent
f rom
P hysical
A ddress)
M I
,
Street
C ity
Z IP
Street
C ity
S tate
Z IP
Proof
o f
R esidency
Grade
L evel
U.S.
C itizen:
Y
N
Is
t he
s tudent
a
m ember
o f
m ultiple
b irths?
☐
☐
Y
N
☐
☐
I f
s o,
i ndicate
t win,
t riplet,
e tc.
_ _______________________
Student’s
C ity
a nd
S tate
o f
B irth
Certified
B irth
C ertificate
D ocument
N o.:
Mother’s
M aiden
N ame
Parent/Guardian
I nformation
Is
P arent/Guardian
a ddress
t he
s ame
a s
t he
s tudent:
Y
N
☐
☐
I f
n o,
p lease
p rovide:
S treet
_ ____________________________________
C ity
_ _____________________________
S tate
_ _______
Z IP
_ ____________________
( check
b ox)
☐ Mother
☐ Father
☐ Grandparent
☐ Foster
P arent
☐ Step
P arent
☐ Legal
G uardian
☐ Other
_ _____________________________
A.
Employer
W ork
P hone
Cell/Home
P hone
Email
A ddress
F irst
a nd
L ast
N ame
(check
b ox
)
Mother
Father
Grandparent
Foster
P arent
Step
P arent
Legal
G uardian
Other
_ _____________________________
B.
Employer
W ork
P hone
Cell/Home
P hone
Email
A ddress
F irst
a nd
L ast
N ame
Previous
S chool
I nformation
Y
N
Has
t he
s tudent
a ttended
a
D PS
s chool
b efore
( incl.
P K,
K )?
☐
I f
Y es,
s chool
n ame
_ ____________________________________________________
☐
Previous
N on-‐DPS
S chool:
_ _____________________________________________
_ ____________________________________________________________________
N ame
S treet
A ddress
C ity
S tate
Z ip
List
O ther
C hildren
I n
F amily
N ame
B irthdate
R elationship
t o
S tudent
S chool
A ttending
G rade
1.
_ _____________________________/___/______________________________________________________________________________
2.
_ _____________________________/___/______________________________________________________________________________
3.
_ _____________________________/___/______________________________________________________________________________
Emergency
C ontact
I nformation
MY
C HILD
M AY
B E
R ELEASED
T O
T HE
F OLLOWING
I NDIVIDUALS:
First
a nd
L ast
N ame
Relationship
t o
S tudent
Daytime
P hone
First
a nd
L ast
N ame
Relationship
t o
S tudent
Daytime
P hone
Modified
0 3-‐2015
1
o f
2