Registration Form (Page 2 of 2) in pdf

PLEASE COMPLETE BOTH SIDES OF THIS FORM!

Student Name

School

FSI

The following survey questions are designed to provide each student high quality educational and/or

supplemental services:

Is a language other than English used in the home?

If yes, language used______________________________

Yes

Does the student have a first language other than English?

Yes

Does the student most frequently speak a language other than English?

If yes, language used______________________________

Yes

Do you currently live: (check one)

In a shelter?

With more than one family in a house or apartment?

In a motel, hotel or campsite?

In a vehicle or outdoors?

With friends or family members?

None of the above.

Have you, or has anyone you know worked in the farming/agricultural

industry in the past three years?

Yes

Do you reside in low rent housing (such as Section 8 subsidized housing)?

Yes

Do you live or work on federal property/facility, Indian lands?

Yes

Is either parent a member of the uniformed services of the United States?

Yes

If yes, please indicate which division:

Air force

Army

Coast Guard

National Guard

Navy

Marines

The above information is correct and complete to the best of my knowledge. In the event of a change of name, address, or

phone, I will notify the school office within ten (10) days. I understand that students whose parents are found, after

appropriate investigation, to have submitted fraudulent information in an effort to enroll a student in a school to which the

student is not assigned shall be immediately withdrawn by the school and the parent must enroll the student in the

appropriate boundaried school or follow the reassignment procedures. I have read and understand the Providing Proof of

Residence: Important Information for Parents (SBP.5.1) and understand that if I have submitted fraudulent or false

information, I may be referred to law enforcement for prosecution.

Print Parent Name _______________________________________________________________________________________

Parent Signature ____________________________________________________Date: _______________________________

I understand that high school credits earned through non-traditional methods, including, but not limited to,

abbreviated course recovery models, or other models outside of the regular classroom and/or school day, or transfer

credits from non-accredited high schools, might not be accepted by certain post-secondary institutions or

organizations.

Parent signature___________________________________ Date __________________________

FORMS:

Immunizations (Form 680)

Health Exam

Medical Exemptions:

Religious

Medical

Temporary (date)______________

Proof of Residency 1________________ Proof of Residency 2___________________

Provisional Domicile or Bona Fide Form (if checked, next review date)_____________

Temporary Custody

Reassignment (Code)__________

ELL

Proof of birth date____________________(specify document)

ESE Program___________________

PROGRAMS

504

SURVEYS:

1__________

2___________

3____________ 4___________

Form 4709 (Rev. 7/12)

PS18614

Registration Form Page 2

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