Student Enrollment Form
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1
2Coopersville Area Public Schools
Office Use Only:
Office Use Only:
STUDENT ENROLLMENT FORM
Birth Certificate
___
Enrollment Date
Immunizations
___
Start Date
198 East Street
Vision Test ___
Admin Approval
Hearing Test ___
Teacher Placement
Coopersville, MI 49404
Need District Release___
Date sent for records
Special Services ___
Bus # _________
The COOPERSVILLE AREA PUBLIC SCHOOLS do not discriminate on
Daycare Class ___
Student I.D. # _______________________
the basis of race, color, religion, sex, national origin, ethnicity, age,
White Cards Distributed
UIC #
height, weight, marital status, or disability.
STUDENT INFORMATION – Legal name – as on birth certificate
Name (first)
(nickname)
(middle)
(last)
Address
City
Zip Code
Phone (
)
(including PO Box)
Township of Residence
County
District of Residence
Gender (M/F)
Birth Date
City & State of Birth
Grade
Is your child Hispanic/Latino? ____Yes ____No
Is your child from one or more of these races? ____American Indian or Alaskan
Native, ____Asian, ____Black, or African American, ____Native Hawaiian/Pacific Islander, or ____White (check all that apply)
Has student attended Coopersville Schools in the past?
Yes
No
If yes, when:
Last school attended
Phone
District
State
Did your child receive Special Education Services? Yes
No
Do you have a copy of the current IEP? Yes
No
Has your child ever been expelled? Yes
No
If so, why?
When:
Do you have any custody issues? Yes
No
Court papers will be required by the school.
Has either parent or guardian served in the U.S. Military Service? Yes
No
Name:
PARENT/LEGAL GUARDIAN INFORMATION:
Legal Name (first)_
(last)
Relationship To Student
Address
City
Zip Code
Phone (
)
Student live with?
Yes No
Send information?
Yes No
Employment
Work Phone
Ext.
E-mail address:
Cell Phone
Legal Name (first)_
(last)
Relationship To Student
Address
City
Zip Code
Phone (
)
Student live with?
Yes No
Send information?
Yes No
Employment
Work Phone
Ext.
E-mail address:
Cell Phone
OTHER – EMERGENCY CONTACTS
Name (first)_
(last)
Relationship to Student
Home Phone ________________________Work Phone
Cell Phone
OTHER – EMERGENCY CONTACTS
Name (first)_
(last)
Relationship to Student
Home Phone ________________________Work Phone
Cell Phone
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