Student Enrollment Form - California
Student Na me:
Date of Birth:
Office Use Onl y
1.
SCHOOL NAME:
6.
LAUSD / STATE STUDENT ID NUMBER:
2.
LOCATION CODE:
7.
HOUSE H O LD NUMBER:
3.
TRACK/SLC:
8.
HOMEROOM:
4.
ENROLLMENT DATE/CODE:
9.
TEACHER/COUNSELOR:
5.
STUDE NT ENTRY GRADE LEVEL:
10.
ENROLLMENT WIZARD USED:
Yes
No
LOS ANGELES U NIFIED SCHOOL DISTRICT
STUDEN T ENROLLMEN T FORM
IN S TR U CT I O N S : Ple ase pr int using blac k or bl ue ink. If you have an y questions , p l ease as k fo r as s istan ce .
A. STUDENT INFORMATION
(LAUSDMAX: Family Member Information)
1.
2.
Legal Name: Last
First
Middle
Alias/Nickname: Last
First
Middle
3.
4.
Home Address: Number
Street
Apt./Unit
City
Zip Code
Home Telephone Number
5.
Sex: Male
6.
7.
Female
Date of Birth
Place of Birth: City
State/Province
Country
B. PARENT/LEGAL GUARDIAN WITH WHOM THE STU D ENT LIVES
(LAUSDMAX: Caretaker Information)
1.
2.
Legal Name: Last
First
Middle
Other Names Used: Last
First
Middle
3.
4.
5.
Day
6.
Home Telephone Number Cell/Pager Number Work Telephone Number
Evening
Email Address
7.
Home Correspondence Language Correspondence is provided in the following languages; select preferred language.
If Other is indicated, written correspondence will be in English.
English Spanish Armenian Chinese Farsi Filipino Korean Russian Vietnamese Other:
8.
Highest Level of Education Completed
Not a High School Graduate
High School Graduate or Equivalent
Some College (includes AA Degree)
Colle ge Gra du at e
Graduate School/Post Graduate Training
Decline to State or Unknown
9.
Does the student live with this parent/legal guardian?
Yes No
10.
Relationship to Student:
C. HOME LANGUAGE AND ETHNICITY INFORMATION
1.
Home La n gu ag e of th e St u de nt
A.
Which language did this student learn when he/she first began to talk?
B.
Which language does this student most frequently use at home?
C.
Which language do you use most frequently to speak to this student?
D.
Which language is most often used by the adults at home?
E.
Has this student received any formal English language instruction (listening, speaking, reading, or writing)?
Yes No
2.
Is the student’s ethnicity Hispanic/Latino?
Yes No
3.
Stude nt’ s Pri mary Rac e (Mark one choice)
African American or Black
American Indian or Alaska Native
White
Asian:
Asian Indian
Cambodian
Chinese
Filipino
Hmong
Japanese
Korean
Laotian
Vietnamese
Other Asian
Pacific Islander: Guamanian Native Hawaiian Samoan Tahitian Other Pacific Islander
4.
Student’s Additional Race (Optional)
African American or Black
American Indian or Alaska Native
White
Asian:
Asian Indian
Cambodian
Chinese
Filipino
Hmong
Japanese
Korean
Laotian
Vietnamese
Other Asian
Pacific Islander:
Guamanian
Native Hawaiian
Samoan
Tahitian
Other Pacific Islander
D. STUDENT EDUCATIONAL INFORMATION
1.
Special Services
If you have any questions regarding this section, please refer to the brochure entitled “Are You Puzzled By Your Child’s Special Needs?”
A.
Was this student receiving special education services at his/her previous school?
Yes No
B.
Did this student have a current Individualized Education Program (IEP) at the previous school?
Yes No
If Yes, do you have a copy of the student’s IEP with you?
Yes No
C.
Did this student have a Section 504 Plan at his/her previous school?
Yes No
If Yes, do you have a copy of the student’s Section 504 Plan with you?
Yes No
D.
Does the student have difficulties that interfere with his/her ability to go to school or to learn?
Yes No
E.
Has this student been identified for gifted and talented educational services (GATE)?
Yes No
2.
Previous School Information
A.
Has this student previously attended this school?
Yes No
If
Yes
, when?
B.
Has this student previously attended any other school or center in the LAUSD (e.g., early education center, state preschool, SRLDP, Head Start, or other preschool)
Yes No
If Yes, list most recent school/center attended.
Name of School
City/State
Dates Attended
Grade Lev el (s )
C.
Please list last non-LAU SD sch ool stud ent att en ded (incl udi ng early educat i on center, stat e pr esch ool , SRLDP , Head S tart, faith based or oth er preschool):
Name of School
City/State
Type of School
Dates Attended
Grade Lev el (s )
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