Application For Admission Of Child To School
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1
2THE SCHOOL DISTRICT OF PHILADELPHIA
APPLICATION FOR ADMISSION OF CHILD TO SCHOOL
(EH-40 Rev. 8/14 Comm. Code 61602445007)
PARENT/GUARDIAN MUST COMPLETE THIS FORM AND PROVIDE ALL NECESSARY DOCUMENTATION
STUDENT INFORMATION - PRINT ALL ENTRIES
LAST NAME
FIRST NAME
MIDDLE NAME OR INITIAL
DATE OF BIRTH
GENDER
STUDENT I.D.
(SCHOOL USE ONLY)
MO
DA
YR
MALE
FEMALE
HOUSE NO.
DIR
STREET NAME
ST., AVE.,ETC
APT.#
ZIP CODE
HOME PHONE
CHECK ONE ONLY ( √ )
RACE DESIGNATION (CHECK (√) ONE ONLY):
0. WHITE
1. BLACK / AFRICAN AMERICAN
2. HISPANIC / LATINO
3. AMERICAN INDIAN / ALASKA NATIVE
4. ASIAN
5. MULTI RACIAL / OTHER
6. NATIVE HAWAIIAN / OTHER PACIFIC ISLANDER
LANGUAGE SURVEY
English
Other
Other Language (please specify)
1. What language does the family speak at home most of the time?
2. What language does the parent(s) speak to her/his child most of the time?
3. What language does the child speak to her/his parent(s) most of the time?*
4. What language does the child speak to her/his brothers/sisters most of the time?*
5. What language does the child speak to her/his friends most of the time?*
6. What language does the child speak most frequently?*
7.
In what language would you like documents sent home?
English Only
English and Other
If other, which language? ___________________________________
*If the answer to any of these questions is other than English, please contact the Enrollment Center for additional screening.
STUDENT EDUCATION: Complete this section if the child has ever attended school
INDICATE CITY AND TYPE OF SCHOOL CHILD LAST ATTENDED
PHILADELPHIA CITY
OTHER CITY
PUBLIC SCHOOL
NON-PUBLIC SCHOOL
DATE LAST ATTENDED
GRADE LAST ATTENDED
NAME OF SCHOOL
ADDRESS
CITY
STATE
If the student attended school Outside of the United States, do you have his/her school records?
Yes*
No
If yes, please provide a copy for the school
If no, please contact the school to obtain records
* High School students must have transcripts evaluated.
Did child ever attend:
Pre-Kindergarten and/or
Kindergarten
1. Has child ever received Special Education services?
Yes*
No
2. Was child ever enrolled in an Early Intervention Program?
Yes*
No
3. Has child ever received ESOL/Billingual services?
Yes*
No
* If the answer is yes to any of the above 3 questions in this section, please ENROLL child in school and refer parent/guardian to the Principal, or Counselor or Special Education Liaison.
Date child first enrolled in U.S. school: __________________
CONTINUE ON REVERSE SIDE >>
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