2014-15 Enrollment Form - San Diego City Schools

OFFICE ONLY
Student Name: _____________________________________________ Grade:________ Teacher: ____________________________ Room #:______
SAN DIEGO UNIFIED SCHOOL DISTRICT
Preschool-Grade 12 ENROLLMENT FORM 2014-15
Complete Sections I-III and sign page 2. Section IV must be completed by office staff. Please print legibly using black or blue pen.
For full directions, please refer to Completing Your Child’s Enrollment Form available at www.sandi.net/enrollment.
OFFICE ONLY
2. Student State ID (SSID):
I. STUDENT INFORMATION
3. Last name (LEGAL NAME ONLY)
4. Preferred Name:
8. Gender
q Female
q Male
First
Middle
5. Other name(s) used previously (AKA):
6. Birth date:
/
/
Suffix (Jr, II, III)
7. Social Security Number (optional):
---
9. Is child
Hispanic
Or Latino?
qYes
qNo
10. Race: (check all boxes that apply)
qAmerican Indian or Alaskan Native Asian/ Indochinese
Pacific Islander
qBlack or African American
qAsian Indian qCambodian qChinese
qGuamanianqHawaiian
qFilipino
qHmong
qJapanese
qKorean
qSamoan
qTahitian
qWhite
qLaotian
qVietnamese qOther Asian
qOther Pacific Islander
11. Directory-type information may be shared with individuals and organizations authorized to receive this
12. Student email address (optional):
type of information unless it is prohibited by the parent/guardian. See page 9 of the Facts for Parents for the
individuals and organizations. This page also includes the student information that may be released. If you do
not want the information shared, you must select “Opt Out”.
q Opt Out
OFFICE ONLY
13. Date:
/
Address Verified
15. Home phone
(
14. Household address:
City, State:
ZIP Code:
16. Mailing address (if different from household):
City, State:
ZIP Code:
/
)
17. City, State of birth:
18. Country of birth:
19. First enrolled in a CA 20. First enrolled in a US
school (K-12):
school (K-12):
Date:
/
/
Date:
/
/
21. Residential status (check one):
q Homelessness-doubling up (living with someone)*
qInternational Exchange
q Parent/legal guardian (if no other option applies)
q Homelessness-hotel/motel*
q Residential facility
q Foster Family Home (FFH)
q Homelessness-sheltered*
q Hospital (not state hospital)
q Foster Group Home (FGH) (FFA)
q Homelessness-unsheltered
qOther ____________________
q Formal Kinship Care (including NREFM)
*Temporary residence due to financial hardship
21a. qUnaccompanied Youth (living in homelessness and not living with or receiving financial support from a parent/guardian/caregiver)
22. Only if applicable complete and include siblings who are currently in Preschool –Grade 12 in San Diego Unified.
Sibling 1 full name:
Grade:
School name:
Sibling 2 full name:
Grade:
School name:
Sibling 3 full name:
Grade:
School name:
II. CONTACT INFORMATION Provide at least three contacts—if additional space is needed use Notes on back of form.
23. Parent/Guardian/Contact
24. Parent/Guardian/Contact
25. EMERGENCY CONTACTS
(OTHER THAN PARENTS)
Full name:
Yes q
No q
If no, provide address here:
Yes q
No q
If no, provide address here:
Relationship to child:
___________________________
_____________________________
Home phone (
)
___________________________
_____________________________
Work phone (
)
Home phone
(
)
(
)
Cell Phone (
Work phone
(
)
(
)
Cell phone
(
)
(
)
q Interpreter required
q OK to release child
Contact full name
Relationship to child
Lives with child?
)
Full name:
Email address (optional)
Employer
Military (check if applicable):
Active Duty
q
Reserves q
National Guard q Dept of Defense q
Active Duty
q
Reserves q
National Guard q Dept of Defense q
Relationship to child:
Contact primary language
Education level
(select one)
Select one or more for each
contact.
q
q
q
q
q
q
q
q
Not a High School Graduate
High School Graduate
Some College/AA Degree
College Graduate
Graduate School/Post-Graduate
Decline to state
Interpreter required
Access to student info online
q
q
q
q
q
q
q
q
q
Not a High School Graduate
High School Graduate
Some College/AA Degree
College Graduate
Graduate School/Post-Graduate
Decline to state
Report card q Progress report
Interpreter required
Access to student info online
SIGNATURE REQUIRED ON REVERSE
Home phone (
)
Work phone (
)
Cell phone (
)
q Interpreter required
q OK to release child
OFFICE ONLY Student Name: _____________________________________________ Grade:________ Teacher: ____________________________ Room #: _________
OFFICE ONLY
1.Student District ID:
III. QUESTIONS FOR PARENT/GUARDIAN
The following questions provide important information for the school staff. Parents must answer the following questions. Check “Yes” or “No” for each
question where appropriate. Questions 31-33 are for high school students only. Questions 30 & 32 require that you check “Opt Out” or leave blank if you
agree to your child’s participation.
26. Has your child ever received Special Education
services?
q Yes q No
28. Name, city, and state of last school attended:
q Yes q No
29. (For students born outside the U.S., see #18) Was this
child born in a foreign country to diplomatic, military personnel or
other U.S. citizen and granted U.S. citizenship? q Yes
q No
30. (For students in Grades 7, 9, & 11) The district would like
your child to participate in the California Healthy Kids Survey
(CHKS). The survey is anonymous and confidential. If you do not
want your child to participate you must select “Opt Out”
Last grade level completed: __________
31. (For high school students only) Has your
child ever played interscholastic athletics?
27. Has one of the parents/guardians recently engaged in migrant
work or been engaged in migrant work (moved and worked
seasonally in agriculture, lumber or fishery related jobs) in the past
three years?
32. (For high school students only) Federal law requires
release of student information to military recruiters. If you do NOT
want this information released for your child, you must select “Opt
Out”. http://www2.ed.gov/policy/gen/guid/fpco/hottopics/ht-1009-02a.html
q Yes q No
33. (For high school students only) Parents may authorize their child’s school to release educational information, including, but not
limited to, Transcripts, Letters of Recommendation, Financial Aid Forms, GPA Verification Forms, Mid-Year Reports, Class Ranking Status
and Disciplinary Records. By checking “Yes” I am giving permission with the understanding that only State/Federal Financial Aid
Programs/Scholarship Programs/Private Schools/University/College personnel and their authorized agents will have access to my child’s
educational records. Communication with these entities may be done verbally, in writing, or electronically.
q Opt Out
q Opt Out
q Yes q No
The information provided in Sections I-III is true to the best of my knowledge.
û Parent/Guardian/Contact signature (required)
Date
IV. DISTRICT ADMINISTRATIVE INFORMATION – FOR OFFICE USE ONLY
34. Address verification document:
35. Birth verification documents:
q Birth certificate q Affidavit q Church records q Passport
q School records q Unverified
36. School of residence: _______________________________
37. District of residence: ________________________________________________
q Interdistrict attendance permit
q InterSELPA agreement
38. Boundary exception for non-resident student Type: __________________________________ Reason: ____________________________________
ENTRY INFORMATION
39. Previously enrolled in San Diego Unified? q Yes* q No
*If Yes: Last year_______________ School______________________________________ Grade___________
40. Entry date: ______ / ______ / _____
41. Entry reason (check one):
q Enter from within San Diego Unified q Enter from Out of District
q Initial Enrollment K-12
q Preschool Enroll-Not Initial
42. For students new to San Diego Unified entering from within
California:
q Initial Enrollment-Preschool
q Enter from Out of State
q Enter from Charter School within San Diego Unified
43. For students new to San Diego Unified entering from outside of California:
Previous school: ____________________________________________________
Student State ID (SSID) (if known): ______________________
Previous CA district: ___________________________________
City, State: ________________________________________________________
Previous CA school name: ______________________________
EXIT INFORMATION
44. Exit date: ______ / ______ / ______
45. Exit reason (check one):
q Grades PK-6 transfer within San Diego Unified q Grades PK-6 transfer out of San Diego Unified q Grades 7-12 transfer within San Diego Unified
q Grades 7-12 transfer out of San Diego Unified q No Show-Enrollment Dropped q Withdrew Grades PK-6 q Other: ________________________
46a. Immunization status:
q Complete q Incomplete q Exempt
LEGAL BINDINGS/NOTES/ADDITIONAL INFORMATION
46b. Dental Exam (K only)? q Yes q No
SAN DIEGO UNIFIED SCHOOL DISTRICT Preschool-Grade 12 ENROLLMENT FORM 2014-15 (Revised 5/7/2014)

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