Student Enrollment Form printable pdf download

For Office Use Only

Date _____________ BPS ID#___________

Student Enrollment Form

Attendance Area _____________________

Bellevue Public Schools

Impact Aid Status _____________________

School_______________________________

PLEASE PRINT ON BOTH SIDES

Proof of Residency

Birth Certificate

Student Legal Name: ___________________________________________________________________________________

First

Last

Middle

___________________________________________________________________

Home Address:

______________

City

Zip

Home Phone: __________________________________ Gender: _____ Birthdate: _______________________________

(Month/Day/Year)

Mailing Address: _______________________________________________________________________________________

(if different than home)

City

Zip

Birthplace: ___________________________________________ U.S. Entry Date (if applicable) _______________________

State/Country

School Previously Attended: ______________________________________________ Grade Upon Enrollment: _________

School

City

State

I have attended a school in Nebraska before?

Yes

No If yes, what district?__________________________________

Ethnicity (For required federal reporting)- Please check one (1)

Hispanic or Latino

Not Hispanic or Latino

Race (For required federal reporting)- Please check all that apply

White

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

American Indian or Alaska Native

 What language did the student first learn to speak? ________________________________________________________

 What language is spoken most often by the student? _______________________________________________________

 What language does the student most frequently use at home? ______________________________________________

 Is this student currently expelled or suspended from another school district?

Yes

 Are there legal/court restrictions affecting access to this student or his/her records?

Yes

If yes, please clarify: ____________________________________________________________________________

 Is this student a ward of the court?

Yes

Parents or legal guardians living in student’s home:

Adult 1:

_________________________________________________ Relationship to student: ________________

Employer:

_______________________________________________________________________________________

Daytime Phone: _________________________________________________ Cell/Other Phone: _____________________

Adult 2:

__________________________________________________ Relationship to student: ________________

Employer:

_______________________________________________________________________________________

Daytime Phone: __________________________________________________ Cell/Other Phone: ____________________

Family Email (not student’s email): _______________________________________________________________________

List any other parent or legal guardian not living with the student:

Adult 1:

________________________________________________ Relationship to student: __________________

Home Phone:

________________________________________________ Cell/Other Phone: ______________________

Daytime Phone: ___________________________

Adult 2:

________________________________________________ Relationship to student: __________________

Home Phone:

_________________________________________________ Cell/Other Phone: _______________________

Daytime Phone: ___________________________

Mailing Address: _______________________________________________________________________________________

Family Email (not student’s email): _______________________________________________________________________

Mailings pertaining to the student should also be sent to this address:

Yes

Student Enrollment Form

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