Middle School Student Household Information
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2MIDDLE SCHOOL STUDENT HOUSEHOLD INFORMATION
2014‐2015 SCHOOL YEAR
State ID:_________________
For office use only
Student's LEGAL Name:
First/Given
Middle
Surname/Family
All previous names of student:
Note: At this time, public schools are required by federal and state regulations to report ethnicity. Is the student Hispanic or Latino?
□ No, not Hispanic
□Yes, Hispanic or La no
□ Black or African‐American □ American Indian/Alaska Na ve □ Asian □ White □ Na ve Hawaiian or Other Pacific Islander
Note: Failure to answer both questions will result in use of prior racial/ethnic data or an observer identifying for you.
Date of birth:
Place of birth:
Grade:
Gender: M F
Assigned Homeroom:
Bus #
Primary Household/Members
(Please list only those members who live at this address)
Home phone:___________________ □Private
Student Cell Number: _________________________________
________________________________________________________________________
Residence Address:
Number
Street
Apt/Lot
□
________________________________________________________________________
Private
City
State
Zip
________________________________________________________________________
□
Mailing Adress
Private
Number
Street
Apt/Lot
(if different)
________________________________________________________________________
City
State
Zip
□
□
Parent/Guardian 1:
Male
Female ______________________________
_______________________________________________________________
First/Given Middle Last
Relation to student
Employer:___________________________________________ Work phone:_________________________
E‐mail address: _____________________________________ Cell phone:__________________________
□ Legal Guardian □ Phone Messenger □ Portal Access □ Mailing
□
□
Parent/Guardian 2:
_______________________________________________________________
Male
Female ______________________________
First/Given Middle Last
Relation to student
Employer:___________________________________________ Work phone:_________________________
E‐mail address: _____________________________________ Cell phone:__________________________
□ Legal Guardian □ Phone Messenger □ Portal Access □ Mailing
Siblings (School Age)
Name:________________________________________ Age:________________ Grade:______________ School:_____________________
Name:________________________________________ Age:________________ Grade:______________ School:_____________________
Name:________________________________________ Age:________________ Grade:______________ School:_____________________
Name:________________________________________ Age:________________ Grade:______________ School:______________________
Secondary Household/Members (Only for Parent NOT living in Primary Household)
Home phone:___________________ □Private
________________________________________________________________________
Residence Address:
Number
Street
Apt/Lot
________________________________________________________________________
□
Private
City
State
Zip
________________________________________________________________________
□
Mailing Adress
Private
Number
Street
Apt/Lot
(if different)
________________________________________________________________________
City
State
Zip
□
□
Parent/Guardian 1:
Male
Female ______________________________
_______________________________________________________________
First/Given Middle Last
Relation to student
Employer:___________________________________________ Work phone:_________________________
E‐mail address: _____________________________________ Cell phone:__________________________
□ Legal Guardian □ Phone Messenger □ Portal Access □ Mailing
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