Student Withdrawal Request Page 2
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2STUDENT ENROLLMENT INFORMATION
What school is this student registering for? ____________________________________Grade_________
NEW SCHOOL
What school did this student last attend? _________________________City______________ST_______
PRIOR SCHOOL
Last Name__________________________________First name ___________________________________
Middle Name__________________DOB____/____/________ Sex _____ Social Security #________________
Optional
Ethnicity
:
Hispanic or Non Hispanic
( circle one )
Race
(circle all that apply)
Black/African American American Indian/Alaskan Native
Pacific Islander / Native Hawaiian
Asian
White
Birth City ____________ Birth County___________
Birth Country _______________ Birth State _________________
Has this student ever received services for : EL 504 IEP
Has this student ever been expelled? Y / N
What is this student's Mother's maiden name__________________________________________________________
Legal Alert: ______________________________________________________________________
(If yes, a copy of the court order MUST be provided)
Student Health Information
Does your child have a health problem? (check all that apply)
My child has no health problems which would affect his/her school day. Y / N
Allergies to (Nuts, Bees, Food, Other please list)_____________________________________________________
Asthma, is inhaler prescribed? Yes _____ No _____ Home only? _____ Need at school?
Diabetes Type 1 _____ Type 2 _____ What medication taken? __________________________________________
Seizures - what type? ___________________________________________ Date of last seizure? ______________
Behavior/Emotional (ADHD, Depression)
Catheterization
Cancer/Leukemia
Sickle Cell Anemia
Heart Problems _______________________________________________ Date diagnosed? ___________________
Any other condition you would like to tell us about___________________________________________________
Medical Alert:____________________________________________________________________
Home Language Survey
TENNESSEE STATE BOARD OF EDUCATION ESL PROGRAM POLICY 3.207, states that: "Each School District must administer
the Home Language Survey to all students entering the District for the first time."
The information is used to identify the need for English language support services for the student.
1. What is the first language this child learned to speak?
_______________________
2. What language does this child speak most often outside of school?
_______________________
3. What language do people usually speak in your child’s home?
_______________________
Please note : If the answer to question(s) 1, 2, or 3 is not English, The Office of EL will assess the student's English language
proficiency and additional forms will need to be completed.
Statement of Residence: Where does the student stay at night? (Please check ONE)
___Home/Apartment owned or rented by the student's parent/legal guardian
___a campsite ___in an automobile_____With a relative or friend (family does not have a residence)
___Shelter ___in a motel ___Other housing (please explain) ____________________________________________
I certify that the above information is true, accurate, and subject to verification. If any information is found to be fraudulent the student may be subject to
withdrawal and the parent/legal guardian subject to tuition reimbursement (TCA 49-6-3003).
Parent/Legal Guardian signature required for enrollment
__________________________________________________________________
Date ________________________________________________
MNPS use only
Student ID_______________________ Student PIN ___________________
Enrollment stamp here
Start Date ________________________ Enrolled at___________________
ES_____ Center_____________ Zoned School________________________
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