Student Information Form (Page 2 of 2) in pdf

Student Information Form Page 2

Please list and explain any medical or mental health issues the student has that may affect him or her at

school. If the student has a 504 plan, please provide a copy. If your child must bring medication to school,

you will need to sign a separate document in the office when school opens.

Home Language Survey

If not born in the US, date of first enrollment in US school?

What was the student’s first language when beginning to talk?

What languages does the student understand?

What language does the student use most at home?

Has your child been enrolled in English Language Learning (ESL) programs before?

Does the parent or guardian require an interpreter when visiting the school? What language is

needed?

_______________________________________________________________________________

Learning Needs

Please describe any special learning needs the student has

Does the student have an IEP (special ed plan) at his or her current school?

(If so, please provide a copy of the IEP).

How old was the student when he or she started school (in any country)?

Has the student missed any months or years of schooling since age 6?

If yes, please explain

Demographics

Student is ____ male ____ female.

Is student Hispanic/Latino? ____ yes ____ no

Please select student’s race (these are US government categories)

! Asian

! American Indian or Alaskan Native

! Native Hawaiian or Pacific Islander

! Black

! White

Student Information Form Page 2