Usd 382 Enrollment Form printable pdf download

USD 382 Enrollment Form

Date Enrolled _________________________ Grade Level:___________

Student’s Legal Name____________________________________________________________________________________________

Last

First

Middle

Home Address: _________________________________________________________________

Home Phone:________________________________

City: ____________________________________ State:____________ Zip: _________________

Gender: _____________ SSN: _________________

Mailing Address:_________________________________________________________________

Birthdate:___________ Birth Place: ______________

City: _______________________________State:_____________ Zip: ______________________

Preferred First Name: _________________________

Resident School District Number: ________________

SchoolMessenger #1(_______)____________________________________

SchoolMessenger #3(________)_________________________________

SchoolMessenger#2 (_______)____________________________________

SchoolMessenger email address: ________________________________

Father/Guardian: _________________________________________________________________ Email Address: _______________________________

Home Phone: ____________________________________________________________________ Cell Phone: __________________________________

Employer: _______________________________________________________________________ Work Phone: ________________________________

Mother/Guardian:__________________________________________________________________ Email Address: _______________________________

Home Phone: _____________________________________________________________________ Cell Phone: __________________________________

Employer: ________________________________________________________________________ Work Phone: ________________________________

Student lives with: Both Parents ___________ Mother _________ Father ___________ Legal Guardian ___________ Other _______________________

Second Mailing Information – Enter only if parent/guardian does not live in the child’s household

Name: ______________________________________________________________________

Email Address: _______________________________

Mailing Address: ______________________________________________________________

Home Phone: ________________________________

City, State Zip: ________________________________________________________________

Work Phone: ________________________________

During the coming year, your child may meet with an accident or become too ill to remain in school. In case of such an emergency, our procedure will be to

contact the parent at home or at work. If this is not possible, the school will contact: 1.) A designated neighbor or relative to care for your child until you can

be reached or 2.) Your physician. It is understood that the schools are not financially responsible for individual medical, dental or hospital service. The

school should be notified if your address or telephone number changes during the school year.

Emergency Contact 1: ______________________________________________ Phone:________________ Relationship: _________________________

Emergency Contact 2: ______________________________________________ Phone:________________ Relationship: _________________________

Emergency Contact 3: ______________________________________________ Phone:________________ Relationship: _________________________

Doctor’s name: ____________________________________________________ Phone: _________________________________________

Race and Ethnicity: (Note: Both Part A and Part B of the question must be answered.)

Part A:

Is this student Hispanic/Latino? (Choose only one)

No, not Hispanic/Latino

Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish

culture or origin, regardless of race.)

The above part of the question is about ethnicity, not race. No matter what you selected above, please continue to answer the following by marking

one or more to indicate what you consider your student's race to be.

Part B:

What is the student's race? (Choose one or more)

American Indian or Alaska Native (A person having origins in any of the original peoples of North and South America (including Central America

and Mexico), and who maintains tribal affiliation or community attachment.) Examples: Azteca, Zapotec, Maya, Nahua, Aymara, Kichwa, Lakota,

Navajo, Guarani.

Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example,

Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.)

Black or African American (A person having origins in any of the black racial groups of Africa.)

Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific

Islands.)

White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.) Examples: Middle Eastern; A person

having origins in any of the original peoples of Egypt, Israel, Iraq, Jordan, Lebanon, Palestine, Syria, or Turkey. Spanish; A person having origins in

any of the peoples of Spain

Updated 5 /2015

Usd 382 Enrollment Form

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