Dps-Enrollment-Form - Cass Technical High School Page 2

Student   E thnicity   a nd   L anguage  

 

We   e ncourage   y ou   t o   s elect   a n   a nswer   f or   S tudent   E thnicity   a nd   L anguage.   I f   y ou   d o   n ot   c hoose   a n   a nswer,   t he   U .S.   D epartment   o f   E ducation  

requires   t he   s chool   d istrict   t o   s upply   a nswer   o n   y our   b ehalf.  

 

Student   E thnicity:  

NO,   N ot   H ispanic

YES,   H ispanic/Latino

( Choose   o nly   o ne)

                    I s   t he   s tudent   H ispanic/Latino?     ☐

          ☐

     

 

 

                    W hat   i s   t he   s tudent’s   r ace?     ☐ American   I ndian   o r   A laska   N ative           ☐ Asian           ☐ Black   o r   A frican   A merican         ☐ White             ☐ Native   H awaiian/Other   P acific   I slander  

                                                                                                                            ☐ Other   _ _________________________________________       C ounty   o f   O rigin   _ _________________________________________                  

Student   L anguage:  

YES      

NO      

   

                      I s   y our   c hild’s   n ative   l anguage   a   l anguage   o ther   t han   E nglish?     ☐

I f   y es,   w hat   l anguage?

_ _________________________________                  

☐

YES  

NO    

                    I s   y our   c hild   a ble   t o   u nderstand,   s peak,   r ead,   A ND   w rite   a   l anguage   o ther   t han   E nglish   a t   t he   N OVICE   L EVEL?   ☐

I f   y es,   w hat   l anguage?__________________  

☐

YES      

NO    

   

                    I s   t he   p rimary   l anguage   u sed   i n   c hild’s   h ome   a   l anguage   o ther   t han   E nglish?   ☐

I f   y es,   w hat   l anguage?

_ ________________________________                  

☐

YES      

NO    

                    H as   t he   s tudent   e ver   b een   e nrolled   i n   a   B ilingual   o r   E nglish   L anguage   L earner   P rogram?     ☐

 

☐

               

YES      

NO    

H as   y our   c hild   s uccessfully   c ompleted   s chooling   i n   a nother   c ountry   f or   a t   l east   a   s emester   ( 4-­‐6   m onths)?     ☐

           

☐

YES      

NO    

                                      I f   y es,   d o   y ou   h ave   t he   o fficial   t ranscripts   ( school   r eport)   f rom   s uccessful   a nd   c ontinuous   s chool?     ☐

 

☐

YES      

NO                             D ATE   E NTERED   U SA:   _ ___/____/____                           B irth   C ountry:   _ _________________  

                    W as   y our   c hild   b orn   i n   t he   U SA?     ☐

☐

                                                                                                                                                                                                                                                                                                                                                                                                                          M onth             D ay                     Y ear      

Parent/Guardian   I nformation:  

YES    

NO      

                      D oes   t he   p arent/guardian   r equire   o ral   o r   w ritten   c ommunication   f rom   t he   s chool   i n   a   l anguage   o ther   t han   E nglish?   ☐

☐

                 

 

Written        

Oral      

I f   y es,   w hat   l anguage?

_ ________________________         ☐

W hat   l anguage   d o   y ou   s peak   m ost   o f   t he   t ime?   _ ________________________    

☐

   

   

Elementary                  

High   S chool          

College          

Masters/PhD        

Other

R elationship   t o   S tudent

E DUCATION

_ ________________________                    

      ☐

 

☐

☐

☐

☐

 

 

Special   C ircumstances   /   P ersonal   E mergencies  

 

Y  

N

Are   t here   a ny   s pecial   c ircumstances   o f   p ersonal   e mergencies   y ou   m ay   w ant   t he   d istrict   t o   b e   a ware   o f?       ☐

      ☐

 

If   “ yes”,   p lease   d escribe:  

Medical   I nformation  

Special   E ducation   P rograms  

 

 

Y  

N

Please   check   the   appropriate   box   below,   if   your   student   has   ever  

Does   y our   s tudent   h ave   a   m edical   c ondition   y ou   w ant   t he   s chool   t o   b e   a ware   o f?       ☐

      ☐

 

participated   i n   s pecial   e d.   p rograms   s uch   a s:  

Y  

N

Does   y our   s tudent   n eed/take   p rescription   m edication?     ☐

      ☐

 

 

☐ IEP           ☐   5 04   P lan     ☐   O ther   _ __________________________  

If   “ yes”,   p lease   l ist:    

 

Military   F amily  

Migrant   S tudents  

 

 

Is   the   parent   or   legal   guardian   currently   serving   in   any   component   of   the   Army,   Navy,   Air   Force,  

Has   the   parent   or   legal   guardian   moved   in   the   past   three   years  

Marines,  or  Coast  Guard?    This  includes  children  of  any  uniformed  personnel  serving  with  the  Michigan  

looking   for   temporary   or   seasonal   employment   in   agriculture   or  

Y  

N

Y  

N

National   G uard,   i n   a ny   o f   t he   R eserved   U nited   S tates   f orces,   o r   o n   A ctive   D uty.       ☐

      ☐

 

fishing   w ork?       ☐

      ☐

 

Discipline  

 

Y  

N  

Has   t he   s tudent   e ver   b een   s uspended   f rom   a   p revious   s chool   o r   a ny   s chool   d istrict?       ☐

      ☐

 

  1   –   9   d ays  

  1 0   d ays   o r   m ore                       E xplain   t he   o ffense:

If   “ yes”,   i ndicate:     ☐

      ☐

 

 

 

Has  the  student  withdrawn  from  any  previous  school  when  disciplinary  charges  were  pending  or  after  being  accused  of  violating  school  policy  or  committing  a  disciplinary  

Y  

N  

offense?       ☐

      ☐

 

If   “ yes”,   p lease   e xplain:      

 

 

 

 

ACKNOWLEDGEMENTS   &   S IGNATURE

 

I   c ertify   t hat   t his   i nformation   i s   t rue   a nd   c orrect.     I f   n ecessary   I   w ill   a llow   a n   i nterview   b y   t he   A ttendance   D epartment   t o   v erify   t his   d ata.  

 

I   u nderstand   t hat   i ncorrect   i nformation   c ould   b e   g rounds   f or   r evoking   e nrollment.     I   u nderstand   t hat   i t   i s   m y   r esponsibility   t o   i nform   t he  

appropriate   s chool   o ffice   i f   a nd   w hen   a ny   i nformation   o n   t his   f orm   c hanges.  

 

By   s igning   t his   E nrollment   F orm,   I   a ccept   a nd   a gree   t hat   i f   a ny   s tatements   a nd   i nformation   c ontained   o n   t his   E nrollment   F orm   a re   n ot   a ccurate  

and   t rue,   I   w ill   b e   p ersonally   l iable   t o   p ay   t o   t he   s chool   d istrict,   t uition   f or   t he   s tudent   ( at   t he   h ighest   r ate   a llowable   b y   l aw)   f or   a ll   p eriods   o f  

time   t he   s tudent   w as   a   n on-­‐resident   p upil   o f   t he   s chool   d istrict   –   i ncluding   a ttorney   f ees   i ncurred   b y   t he   s chool   d istrict   i n   c ollecting   t he   t uition.  

 

______________________________________________________________                                             _ _____________________________________________  

Parent   o r   G uardian   S ignature  

 

 

 

 

 

Date                                                            

Modified   0 3-­‐2015  

2   o f   2