Student Number: ________________________________
Enrollment Date: ______________________
Grade Level: __________________________
E1
R3
init Enroll this year
Transfer from another LEA
Student Enrollment Form
E2
R5 Re-enroll Previous W1
init Enroll from non-NC Sch
R2
R6 Re-enroll Previous W2
Transfer within same LEA
(Please PRINT all information)
For Office Use Only
Student’s Legal Name: ____________________________________________________________________________________
Last
First
Middle
Home Street Address: _____________________________________________________________________________________
Mailing Address: (if different) ______________________________________________________________________________
Date of Birth: ____/_____/_____
Gender:
Male ☐
Female ☐ Contact Phone Number: _________________________
Ethnicity: (choose one) Hispanic ☐
Non-Hispanic ☐
Race:
hite ☐
African-American ☐
(check all that apply)
W
Grade: __________
Hawaiian/Pacific Islander ☐ Asian ☐ American Indian or Alaska Native ☐
Father/Guardian Name: ___________________________________________ Father ☐ Step-Father ☐ Guardian ☐
Address: ____________________________________________________________ Home Phone: _______________________
Cell Phone: __________________________ Employer: _______________________ Work Phone: _____________________
E-mail address: ___________________________________________________________________________________________
Mother/Guardian Name: __________________________________________ Mother ☐ Step-Mother ☐ Guardian ☐
Address: ____________________________________________________________ Home Phone: _______________________
Cell Phone: __________________________ Employer: _______________________ Work Phone: _____________________
E-mail address: ___________________________________________________________________________________________
If parents are separated or divorced, who has primary custody? ____________________________________________
How was custody awarded? *You must provide a copy* Court Order ☐ Written Separation Agreement ☐
Does the Court Order or Separation Agreement limit the non-custodial parent’s rights? Yes ☐ No ☐
Presently, the student is living:
In apartment or home at _________________________________ ☐
In a shelter ☐
Address
With Friends or relatives temporarily (with parent/guardian) ☐
In a motel, car or campsite ☐
With friends or relatives (without parent/guardian) ☐
Other, please explain ☐ ________________
Sibling Information:
Name of Sibling*
Relationship
Current School
Grade
*List only siblings who
are currently in school
Educational Information:
Name of last school attended: ______________________________City: __________________________ State: _________
Grade while attending: __________ Has student attended school in NC before? Yes ☐
No ☐
Has student attended a pre-school? Yes ☐ No ☐ Name of school: _______________________________________
CCS Student Enrollment
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