Chesterfield County Public Schools Student Registration Form
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4Chesterfield County Public Schools Student Registration Form
Student’s Full Legal Name
Grade: ____
Student ID#________________________________
(Exactly as shown on birth certificate)
__________________________________________________________________________________________
Legal Last Name
Legal First Name
Legal Middle Name
Suffix
Date of birth: _____ _____ ______
Birth Certificate #___________________
Gender:
Male
Female
Month
Day
Year
Country of Birth________________
State of Birth____________________
City of Birth______________________
Is the student an Immigrant ?
Yes If yes entry date in U.S. Schools _____________
No
Immigrant – Individuals who are school aged 3 through 21; were not born in any State of the United States of America (including Puerto Rico and D.C.); and have not
been attending one or more schools in any one or more States for more than three (3) full academic years.
Primary Language Spoken: What language is spoken in your home most of the time? ___________________
What language does your child speak most of the time? ___________________
If Language other than English contact the ESOL Welcome Center
Ethnic Group-
The US Department of Education requires that both these questions be answered and provides only the following categories for ethnic group and
race. If both questions are not answered, school personnel are required to make selections for both.
Is the student Hispanic or Latino?
No - Not Hispanic or Latino
Yes - Hispanic or Latino
Race:
Select all that apply
American Indian or Alaska Native
Asian
Black/African American
White
Native Hawaiian or Other Pacific Islander
*******************************************************************************************************
Primary Address of Student/ Enrolling Parent
Relationship: Mother
Father
Legal Guardian
Foster Parent
Other______________________
Last Name
First Name
Middle Initial
Suffix
Address________________________________________________________________ City____________________________ State_______ Zip_________________
Home Phone Number _______________________________ Cell Number ________________________________ Work Number_____________________________
Mailing address (if different from primary address) ______________________________________________________________________________________________
Address
.
City
State
Zip
Parent Email Address_____________________________________________________________________________________________________________________
Contact Allowed:
Yes
No
Educational Rights:
Yes
No
Custody:
Yes
No
Student Lives with:
Yes
No Release To:
Yes
No
Preferred method of contact:
English
Spanish
Other Parent
Relationship: Mother
Father
Legal Guardian
Foster Parent
Other_____________________
_______________________________________________________________________________________________________________________________________
Last Name
First Name
Middle Initial
Suffix
Address ______________________________________________________________ City ________________________ State _________ Zip__________________
Home Phone Number _________________________________ Cell Number_______________________________ Work Number_____________________________
Email Address____________________________________________________________________________________________________________________________
Contact Allowed:
Yes
No
Educational Rights:
Yes
No
Custody:
Yes
No
Student Lives with:
Yes
No Release To:
Yes
No
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