Sis-10w - Student Enrollment Form

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School Name:
Complex Area:
Student ID No.
Entry Date
Entry Code
Room
STUDENT ENROLLMENT FORM
SIS-10W (Revised)
For school use only
INSTRUCTIONS: PRINT YOUR ENTRIES LEGIBLY
Ethnicity/Race Observed:
_________ Initial
_________ Date
STUDENT PERSONAL DATA
Legal Last Name: ________________________________
Gender:
M
F
Grade Level: __________
Legal First Name: ________________________________
Birth Date: ___________________________
Middle Initial: __________
Suffix: (Jr, II, III, etc): ___________________________
Verification of DOB: ______________________________
Not Homeless
Homeless*
Completed MVA Packet
_____________________________________
_____________________________________
DOE Representative Signature
Parent/Legal Guardian Signature
*“Homeless” means individuals who lack a fixed, regular and adequate nighttime residence (within the meaning of section 42 USCS §11302(a)(1)) and
includes:
(i)
children and youth who are sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason; are living in
motels, hotels, trailer parks, or camping grounds due to the lack of alternative adequate accommodations; are living in emergency or transitional
shelters; are abandoned in hospitals; or are awaiting foster care placement.
(ii) children and youth who have a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular
sleeping accommodation for human beings (within the meaning of 42 USCS §11302(a)(2)(C));
(iii) children and youth who are living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations or similar
settings; and
(iv) migratory children (as such term is defined in section 1309 of the Elementary and Secondary Education Act of 1965) who qualify as homeless for
the purposes of this subtitle.
If you have any questions regarding the above, please call 1-866-927-7095
PRESCHOOL EXPERIENCE
LAST HAWAII PUBLIC SCHOOL ATTENDED
Preschool Experience
Yes
No
Name:
If “Yes” – attended:
Pre-School Program: (if applicable)
less than 6 months
EOEL
Last Grade Attended:
Year:
between 6 and 12 months
KALO
more than 1 year
PDG
PRIOR SCHOOL ATTENDED (If not Hawaii Public School)
Name:
U.S. Phone:
Address:
U.S. Fax:
CITIZENSHIP
Country of Birth: _______________________________
If Country of Birth is other than US, give year of arrival: ____________________
If not US Citizen, indicate status: Refugee
Immigrant
Non-Immigrant
US Citizen:
Yes
No
LANGUAGE INFORMATION
Language Codes:
(Select a letter from the list and fill in the blanks below)
Language (Spoken) at Home
First (Acquired) Language
Language Most Used
A – English
F – Cebuano/Visayan
K – Vietnamese
Q – Fijian
V – Pangasinan
L – Other (Specify):
B – Cantonese
G – Hawaiian
M – Chuukese
R – Hmong
W – Portuguese
________
C – Mandarin
H – Japanese
N – Pohnpeian
S – Lao
X – Spanish
D – Ilocano
I – Korean
O – Cambodian
T – Marshallese
Y – Thai
E – Tagalog
J – Samoan
P – Chamorro
U – Pampango
Z - Tongan
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Page 1/4, SIS-10W Rev 12/16 SPAB

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