Santa Clara Unified School District Student Registration Form Page 2
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1
2SANTA CLARA UNIFIED SCHOOL DISTRICT
STUDENT REGISTRATION FORM
(
Student Name) Last
First
PermID
Grade
III.
ADDITIONAL STUDENT INFORMATION
Languages
1) Which language did your child learn when he/she first began to talk?
ELEF
2) Which language does your child most frequently speak at home?
ELEF
3) Which language do you (the parents or guardians) most frequently use when speaking with your child?
ELEF
4) Which language is most often spoken by adults in the home?(parents, guardians, grandparents, or any other adults)
Previous Schools / Enrollment History
US School Entry Date
/
/
California School Entry Date
/
/
Last School Attended
School District
School Address
City
State
Phone (
)
Fax (
)
Date left previous school
/
/
Has student previously attended a school in the Santa Clara Unified School District?
No
Yes (if yes) School
Date left SCUSD School
/
/
Has student ever been
Has student ever been expelled from school?
Yes
No
Yes
No What grade?
retained?
Special Programs
Please check if student has received any special services or participated in any of the following programs.
ELL/Bilingual Program
Gifted and Talented
Migrant Education
IEP
Resource Specialist
Special Day Class
Speech/Language
Title I
Other
Other Family Members
Names of other children in the family
Birthdate
Relationship to Student
/
/
/
/
/
/
/
/
Non-Custodial Parent or Joint Custodial Parent
Name:
Last
First
Middle
Language Spoken
Email
@
—
Work Phone No.
(
)
Address
—
Cell Phone No.
(
)
City
State
Zip Code
—
Other
(
)
Relationship to Student
Marital Status
Mother
Step Mother
Legal Guardian
Married
Single
Divorced
Widowed
Father
Step Father
Other
I have reviewed this two page document and to the best of my knowledge, the information contained herein is true and complete.
The undersigned declares under penalty of perjury that they are the parent or legal guardian of the above-named student.
Parent / Guardian Signature
Date
/
/
For School Use Only
School
Date
/
/
PermID
Family #
Blank
ET
RC
Open Enrollment
Home School #
Teacher
Room
Counselor
In District Transfer
Home School #
Records Requested
/
/
Date Entered
/
/
Overload
Home School #
Birth Certificate
Hospital Certificate
Baptismal
Passport
Out of District Transfer
District #
Address Verification
By (initial)
Date
/
/
Rev 10.11.2012
Registration Form scusdRegFormV02.1 2011-2012
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