Care And Treatment Enrollment Form
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12015-2016
Care & Treatment Student Enrollment Form
and Non-Resident Tuition Acknowledgement
287 Student ID # _____________________________
Today’s Date ____________________________________________
RETURN FORM TO: _________________________________
School Name & Number ___________________________________
Address ________________________________________________
STUDENT NAME (Use legal name and permanent address only.)
(CE220)
Last ___________________________________________________ First ________________________ Middle ___________________
Street Address (CE010) __________________________________________________________ APT:____________________________
City __________________________________________________________ State: MN_____ Zip Code _________________________
Home Phone (______) ________________ Work Phone (______) ___________________ Cell Phone (______)___________________
Birth date: (CE220) MM ______
DD ______ YY _______
Age _______________
Gender:
M
F
Is this student Hispanic/Latino?
Yes
No
Primary Ethnicity:
White(5)
Black(4)
Hispanic(3)
Asian/Pacific Islander(2)
Native American/Alaskan Native(1)
What is the student’s race? (choose one or more):
Black/African American
Native American/Alaska Native
Asian
White
Native Hawaiian/Pacific Islander
Primary Home Language(CE220) __________________________________ Student Birth Country(CE221) ________________________
“Have you recently moved to this school district within the last 36 months for temporary or seasonal agricultural or fishing work?”
Yes
No
WITH WHOM DOES THE STUDENT LIVE? (c
one)
Father & Mother
Father & Stepmother
Mother & Stepfather
Father only
Mother Only
Legal Guardian(s)
Foster Parent(s)
Grandparent(s)
Other_______________
PARENT/GUARDIAN #1 Relationship _____________________
PARENT/GUARDIAN #2 Relationship _____________________
Last _______________________ First ______________________
Last _______________________ First ______________________
Address (if different from above)
Address (if different from above)
Street________________________________ APT_______
Street______________________________ APT_________
City _______________________ State ______ Zip ____________
City _______________________ State ______ Zip ____________
Phone (H) __________________ (W) _______________________
Phone (H) __________________ (W) _______________________
Cell __________________________________________________
Cell __________________________________________________
Spec Ed Evaluation Status
__________________________
Grade Level _________
Yes
No
(SP205)
Primary Disability ___________
Instructional Setting _________
Transportation Code ________
Transportation District ________
MARRS#
Grad Standards Year (GSY) ______________________________
(NOTE: GSY must be completed for all students in ninth grade or over.)
ENROLLMENT DATE
MM_____ DD_____ YY_____ Limited English Proficient:
Yes
No (LEP Start Date ______________)
(ST208):
State Aid Category: 27
Resident District ___________________________________ Post-Secondary Options:
Yes
No
Last School Attended ____________________________ Month ___________________ Year ___________ Previous District # _______
Compensatory Aid 0 1 2
FTE % __________ School Code ___________ Last Location of Attendance Code __________________
Post-Secondary Options:
Yes
No
Opt Out:
GAMC
Yes
No
ADMINISTRATOR—We acknowledge that the student listed above is a resident of our school district, and we expect to be billed for instruction
and service costs provided for this student during the indicated school year by Intermediate District 287. Credits earned will be accepted and the
information contained on this document is correct to the best of our knowledge.
____________________________________________________________
_____________________________________
______________________
Resident District Administrator or Designee
School District
Date
White — MARSS Copy (287)
Yellow — Program Pink — Resident District Administration MARSS Form 1 (Rev. 8/2011)
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