New Student Registration Form - Burlington School District Form Page 2
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1
2Yes___ No___ (If Yes please fill out next boxes 1-4)
Student is an Immigrant:
Year First started school in
Year entered country
Immigrated From
First date enrolled in US school
country not United States
1
3
4
2
Migrant Status: Yes___ No____ (In the last three years have you moved with family/guardian to Burlington in search of temporary or seasonal work in agriculture or logging.)
Student is in state Care and Custody: Yes_____ No_____
(If Yes, please fill continue to fill out the rest of this section.)
Student a Burlington Resident Yes______ No______ Resident City (if Not Burlington):____________________________________________
Caseworker Name:
Caseworker Phone Day or Cell:
Night or Cell
Agency Name and Address (Street #, Street Name, Apt no, City, State, Zip):
Parent/Guardian Information
Name:
Relationship: Mother__ Father__ Legal Guardian __ Other______________________________
Lives with Student: Full Time___ Part Time____ Has custody of Student: Yes__ No__
Gets Mailing for Student: Yes____ No____
Education
8th grade | 9th grade | 10th grade | 11th grade | 12th grade
Requires a translator: Yes__ No__
(circle highest completed level):
some college | 2 year college degree | 4 yrs college | grad school
Correspondence Language:_________________________
Home Phone
Day or Cell Phone
Night or Cell Phone
E-mail
Unlisted_____
Unlisted_____
Unlisted_____
Address if not the same as student’s physical
(Street #, Street Name, Apt no, City, State, Zip):
Guardian does not live with student, would like a second mailing of student correspondence to the above address. Yes____ No____
Employer:____________________________________
Parent/Guardian Information
Relationship: Mother__ Father__ Legal Guardian __ Other______________________________
Name:
Lives with Student: Full Time___ Part Time____ Has custody of Student: Yes__ No__
Gets Mailing for Student: Yes____ No____
Education
8th grade | 9th grade | 10th grade | 11th grade | 12th grade
Requires a translator: Yes__ No__
(circle highest completed level):
some college | 2 year college degree | 4 yrs college | grad school
Correspondence Language:_________________________
Home Phone
Day or Cell Phone
Night or Cell Phone
E-mail
Unlisted_____
Unlisted_____
Unlisted_____
Address if not the same as student’s physical
(Street #, Street Name, Apt no, City, State, Zip):
Guardian does not live with student, would like a second mailing of student correspondence to the above address. Yes____ No____
Employer:____________________________________
Provide the name(s) of person(s), other than the parent, allowed to pick up student or to call in case of an emergency
Name (first, middle initial, last)
Relationship to student
Telephone #
Telephone #
I certify that all the information on this student registration form is true and correct to the best of my knowledge and belief.
Parent or Guardian Signature____________________________________ Date_____________ Print Name______________________________________
Student ID:
Enrolling Home School and grade
Projected grad year
Projected middle school
School Enrollment Date
For Internal
Use Only
_____________
________________________(________)
_________________
_____HMS _____EMS
____________________
* Mandatory
*___Completed Student Registration Form
___Food Service given completed Lunch Form
Forms for
*___Birth Certificate on File
___Kindergarten Parent Survey Completed
Completion
*___Proof of Residency on file
___Team__________________________________________
*___Primary Home Language Survey completed Date:___________
___Guidance Counselor_______________________________
*Languages: Home, Dominant______________________________
___Home Study Student
Date
*Languages: Native, Other_________________________________
___Act150 student
Received
*___Migrant Education Program employment Survey completed
___State Placed
*___Immunization/Health records filed with Nurse
___Part Time Student Yes____ No____
__________
*___District Home School_________________________________
___Part Time Hours __________________
(District Home School = Elementary school zone based on physical address)
___Student record transfer request made
___Health/Emergency contact form on file with nurse
___Received records from sending school
___Requested Magnet school - Completed Magnet Application
___Education of Parent/Guardian
Rev-BSD2011-102
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