Sis-10w - Student Enrollment Form Page 2
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1
2
3
4Please complete ETHNICITY INFORMATION, RACE INFORMATION, and PRIMARY ETHNICITY/RACE INFORMATION
ETHNICITY INFORMATION
Are you (J) Hispanic (Ex. Cuban, Mexican, Puerto Rican, Spanish, Other Hispanic)?
Yes
No
RACE INFORMATION
Check all that apply:
A – American Indian or Alaska Native
E – Native Hawaiian
K – Samoan
P – Tongan
B – Black
G – Japanese
L – White
Q – Guamanian/Chamorro
C – Chinese
H – Korean
R – Other Asian
N – Indo-Chinese (Ex. Cambodian,
Laotian, Vietnamese)
D – Filipino
I – Portuguese
S – Other Pacific Islander
O – Micronesian (Ex. Chuukese,
Marshallese Pohnpeian,)
PRIMARY ETHNICITY/RACE INFORMATION
What is the student’s primary race? (Select only ONE letter from either the ethnicity or race list and fill in the blank) ________
I decline to provide ethnicity and race information. I understand that if I do not provide this information, a school representative will designate the
ethnicity and race categories for my child.
LIVING IN THE HOUSEHOLD WITH STUDENT
LEGAL PARENT/GUARDIAN
Is
Check one:
Mr.
Mrs.
Ms.
Other (specify): ______________________
Relation: ___________________________
Marital Status:
Married
Divorced
Separated
Single
Custody of Child:
Yes
No
Custody Documentation Submitted:
Yes
No
Custody Type:
Sole Custody
Physical Custody
Joint Legal
F
________________________________________________
______________________________________
I
Legal Last Name
Legal First Name
R
S
T
Home Address: _____________________________________________________ APT# ________ City ____________________ Zip ___________
P
Mailing Address (if different from Home Address): _______________________________________________________________________________
A
R
E
__________________________
__________________________
__________________________
__________________________
N
Home Phone #
Cellular Phone #
Pager #
Work Phone # (include ext.)
T
/
G
Email Address: ___________________________________________________________________________________________________
U
A
Allow this person access to:
(circle all that apply)
mailing / portal (if applicable) / messenger
R
D
I
EMERGENCY CONTACT:
(circle one)
Call Sequence
1
2
A
N
Is this parent/guardian a member of the Armed Services, National Guard or Reserves?
Yes
No
Military Status (check one):
Traditional Reservist / M-Day
Active Duty (Title 10)
Federal Technician (Title 32)
Deployed?
Yes
No
Branch of Service (check one):
Army
Marine
Air National Guard
Navy Reserves
Air Force
Coast Guard
Army Reserves
Marine Reserves
Navy
Army National Guard
Air Force Reserves
Coast Guard Reserves
Does this person work for the Federal Government or work on Federal Property?
Yes
No
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Page 2/4, SIS-10W Rev 12/16 SPAB
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