Enrollment Form 2016-17
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2FOR OFFICE USE ONLY
Gull Lake Community Schools
Verification of Birth Certificate Yes No
Verification of Immunizations Yes No
ENROLLMENT FORM 2016-17
Yes No
Verification of Residency
State ID
Student Number
Re-enrolling in a Michigan Public School? Yes No
Locker Number
Comb.
Date last attended a Michigan Public School: ______________
Homeroom/Teacher
Bus # (Pickup)
Bus # (Drop-off)
School District last attended __________________________________
st
Building
1
Day of Attendance
STUDENT INFORMATION
Student Name: ______________________________________________________ Nickname: _____________________________
(From Birth Certificate)
(LAST)
(FIRST)
(MIDDLE)
(OPTIONAL)
Gender: Male Female Birthdate: ___ /___ /____ Age: ______ Grade: _______ Student Email Address: ____________________
Has the student been previously suspended or expelled? Yes No
If Yes, please explain__________________________________________
_______________________________________________________________ If Yes, which district? ______________________________________
ETHNICITY (Part A) and RACE (Part B)
Race and Ethnicity (Both Part A and Part B) of the question must be answered. If either part is
not answered, the US Department of Education requires the district to supply an answer on your behalf.
Part A:Ethnicity
Is this student Hispanic/Latino?
(A person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture
Yes No
(choose only one)
or origin, regardless of race.)
Part A refers to ethnicity, not race. No matter which box you selected above, please continue to answer
.
Part B (below) by marking one or more boxes to indicate what you consider your student’s race to be
%____ American Indian or Alaska Native
Part B:Race
(Origins from any of the original peoples of N, S, or Central America)
(choose one or more)
%____ Asian
(Origins from any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent)
When choosing more
%____ Black or African American
(Origins from any of the black racial groups of Africa)
than one, enter % for each
%____ Native Hawaiian / Other Pacific Islander
(origins from any of the original peoples of any Pacific Island)
ethnicity
%____ White
(Origins from any of the original peoples of Europe, the Middle East or N Africa)
PRIMARY HOUSEHOLD INFORMATION
Home Phone Number: (___)________________ Unlisted ( ) Phone Number for Attendance Calls: (___)___________ Unlisted ( )
Primary Email Address: ______________________________________
Is the primary language used in your child’s home or environment a language other than English? Yes No
If yes, what is that language? _______________________
Resident District _________________________________
Is your child’s native tongue a language other than English? Yes No If yes, What is that language? ___________________
used in your child’s home or environment a language other than English? Yes No If yes, What is that
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Is the primary language
language? ______________________
Current Physical Address: __________________________________________________________________________________
(STREET ADDRESS)
(CITY)
(STATE)
(ZIP)
(COUNTY)
Current Mailing Address: __________________________________________________________________________________
(if different)
(STREET ADDRESS)
(CITY)
(STATE)
(ZIP)
PRIMARY HEAD(S) OF HOUSEHOLD (With whom does the child reside?)
Adoptive Parents
Father Only
Relative (______________)
Birth Parent(s)
Legal Guardian
Double-Up
Father/Stepmother
Emancipated Minor
Hotel/Motel
Mother/Stepfather
Shelter
Grandparents
Mother Only
Foster Home (less than 6 months?)Yes No
Other (______________)
PRIMARY HOUSEHOLD DATA
PRIMARY RESIDENT 1
PRIMARY RESIDENT 2
Head of Household Name/Title (Last, First)
Relationship Type
Occupation/Employer
Employer Phone
*Additional Notes for above Phone Number
Cell Phone / Pager
*Additional Notes for above Phone Number
Email Address
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