Student Enrollment Form
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1
2
3Student Name:
Date of Birth:
Office Use Only
1.
6.
SCHOOL NAME:
LAUSD / STATE STUDENT ID NUMBER:
2.
7.
LOCATION CODE:
HOUSEHOLD NUMBER:
3.
8.
TRACK/SLC:
HOMEROOM:
4.
9.
ENROLLMENT DATE/CODE:
TEACHER/COUNSELOR:
5.
10.
Yes
No
STUDENT ENTRY GRADE LEVEL:
ENROLLMENT WIZARD USED:
LOS ANGELES UNIFIED SCHOOL DISTRICT
STUDENT ENROLLMENT FORM
INSTRUCTIONS: Please print using black or blue ink. If you have any questions, please ask for assistance.
A. STUDENT INFORMATION
(LAUSDMAX: Family Member Information)
1.
2.
Legal Name: Last
First
Middle
Alias/Nickname: Last
First
Middle
3.
4.
Home Address: Number
Street
Apt./Unit
City
Zip Code
Home Telephone Number
5.
Sex:
Male
6.
7.
Female
Date of Birth
Place of Birth: City
State/Province
Country
(LAUSDMAX: Caretaker Information)
B. PARENT/LEGAL GUARDIAN
WITH WHOM THE STUDENT LIVES
1.
2.
Legal Name: Last
First
Middle
Other Names Used: Last
First
Middle
3.
4.
5.
Day
6.
Home Telephone Number
Cell/Pager Number
Work Telephone Number
Email Address
Evening
Home Correspondence Language Correspondence is provided in the following languages; select preferred language.
If Other is indicated, written correspondence will be in English.
7.
English
Spanish
Armenian
Chinese
Farsi
Filipino
Korean
Russian
Vietnamese
Other:
Highest Level of Education Completed
8.
Not a High School Graduate
High School Graduate or Equivalent
Some College (includes AA Degree)
College Graduate
Graduate School/Post Graduate Training
Decline to State or Unknown
Does the student live with this parent/legal guardian?
10.
Relationship to Student:
9.
Yes
No
C. HOME LANGUAGE AND ETHNICITY INFORMATION
1.
Home Language of the Student
A.
Which language did this student learn when he/she first began to talk?
B.
Which language does this student most frequently use at home?
C.
Which language do you use most frequently to speak to this student?
D.
Which language is most often used by the adults at home?
E.
Has this student received any formal English language instruction (listening, speaking, reading, or writing)?
Yes
No
Is the student’s ethnicity Hispanic/Latino?
2.
Yes
No
3.
Student’s Primary Race (Mark one choice)
African American or Black
American Indian or Alaska Native
White
Asian:
Asian Indian
Cambodian
Chinese
Filipino
Hmong
Japanese
Korean
Laotian
Vietnamese
Other Asian
Pacific Islander:
Guamanian
Native Hawaiian
Samoan
Tahitian
Other Pacific Islander
4.
Student’s Additional Race (Optional)
African American or Black
American Indian or Alaska Native
White
Asian:
Asian Indian
Cambodian
Chinese
Filipino
Hmong
Japanese
Korean
Laotian
Vietnamese
Other Asian
Pacific Islander:
Guamanian
Native Hawaiian
Samoan
Tahitian
Other Pacific Islander
D. STUDENT EDUCATIONAL INFORMATION
1.
Special Services
If you have any questions regarding this section, please refer to the brochure entitled “Are You Puzzled By Your Child’s Special Needs?”
A.
Was this student receiving special education services at his/her previous school?
Yes
No
B.
Did this student have a current Individualized Education Program (IEP) at the previous school?
Yes
No
If Yes, do you have a copy of the student’s IEP with you?
Yes
No
C.
Did this student have a Section 504 Plan at his/her previous school?
Yes
No
If Yes, do you have a copy of the student’s Section 504 Plan with you?
Yes
No
D.
Does the student have difficulties that interfere with his/her ability to go to school or to learn?
Yes
No
E.
Has this student been identified for gifted and talented educational services (GATE)?
Yes
No
2.
Previous School Information
A.
Has this student previously attended this school?
Yes
No
If Yes, when?
B.
Has this student previously attended any other school or center in the LAUSD (e.g., early education center, state preschool, SRLDP, Head Start, or other preschool)
Yes
No
If Yes, list most recent school/center attended.
Name of School
City/State
Dates Attended
Grade Level(s)
C.
Please list last non-LAUSD school student attended (including early education center, state preschool, SRLDP, Head Start, faith based or other preschool):
Name of School
City/State
Type of School
Dates Attended
Grade Level(s)
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