Registration Form
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2Name_____________________________________________Grade_____Teacher______________________________Entry Code__________Entry date_____________
THE SCHOOL BOARD OF BROWARD COUNTY, FLORIDA
STUDENT REGISTRATION FORM
Only the parent/guardian (F.S. 1000.21(5)) who registers the student (i.e., completes this form), may withdraw the student from his/her current
school, unless there is documentation of extenuating circumstances indicating otherwise. If the information below changes, it is the
parent’s/guardian’s responsibility to notify the school within 10 school days.
Student (Legal Name)
Last
First
Middle
Address
Bldg.
Apt.
City
Zip
Home Phone
Cell Phone
Parent email
Student SSN
F.S.I.
(Students' Social Security Numbers are not required for enrollment or graduation.
(Florida Student ID)
Current Grade Level
Sex
Male
F.S. 1008.386 requires SBBC to use the S.S.N. for its management information system.)
Female
Ethnicity: Is the student of Hispanic,
Birth Date
Birthplace City
Latino or Spanish origin?
State or Country
Yes
No
Student lives with:
Parents' Marital Status (optional)
Race
Married
Both Parents
Native American/
White
Divorced
Father
Native Alaskan
Black
Mother
Separated
Native Hawaiian/
Other
Widow(er)
Asian
Pacific Islander
(specify relationship to student)
Other
Parent Information:
Male
Female
Name of registering parent:
Male
Female
Name of other parent:
Address of other parent:
City
State
Zip code
Phone of other parent
Cell phone of other parent
PREVIOUS SCHOOL EXPERIENCE:
Has the student previously attended a:
Has the student previously been:
Broward Public School?
Yes
No
retained (repeated the same grade?)
Yes
No
If yes, indicate name of school.
Yes
No
in a Home Education Program?
Yes
No
Florida Private School?
Yes
No
in Exceptional Student Education (ESE)?
If yes, indicate name of school.
Yes
No
Yes
No
in a Magnet Program?
Florida Public School?
Yes
No
expelled from school?
If yes, indicate name of school.
Yes
No
Yes
No
US School Outside of Florida?
on a 504 plan?
Yes
No
in an ESOL program?
If yes, indicate name of school.
Yes
No
convicted of a felony?
County
Public
Private
living outside of the USA?
Yes
No
School Outside of The US?
Yes
No
If your child previously lived outside of the United
States, state the date your child first entered school
If yes, indicate name of school.
in the USA:
Country
Public
Private
PLEASE COMPLETE BOTH SIDES OF THIS FORM!
Form 4709 (Rev. 7/12)
PS18614
Student Name
School
FSI
The following survey questions are designed to provide each student high quality educational and/or
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