Student Enrollment Form - California

Student Na me:
Date of Birth:
LOS ANGELES UNIFIED SCHOOL DISTRICT
STUDEN T ENROLLMEN T FORM
F. ADDITIONAL FAMILY INFORMATION (Continued)
(LAUSDMAX: Caretaker Information)
PARENT/LEGAL GUARDIAN/CAREGIVER:
1.
2.
Legal Name: Last
First
Middle
Other Names Used
3.
Home Address (if different than student’s) Number
Street
Apt/Unit
City
Zip Code
4.
5.
6.
Day
7.
Home Telephone Number Cell/Pager Number Work Telephone Number Evening E-mail Address
8.
Preferred Correspondence Language
English
Spanish
Armenian
Chinese
Farsi
Filipino
Korean
Russian
Vietnamese
9.
Highes t Le vel 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
10.
Does the student live with this individual?
Yes No
11.
Relationship to Student:
ADDITIONAL SCHOOL AGE CHILDREN LIVING IN HOUSEHOLD WITH SAME PARENT(S)/LEGAL GUARDIAN(S) (include brothers, sisters, and cousins)
1.
Sex:
Male Female
Last Nam e
First Name
Birth Date
Current school and track
2.
Sex:
Male Female
Last Nam e
First Name
Birth Date
Current school and track
3. Sex: Male Female
Last Nam e
First Name
Birth Date
Current school and track
4. Sex: Male Female
Last Nam e First Name Birth Date Current school and track
5. Sex: Male Female
Last Nam e First Name Birth Date Current school and track
6. Sex: Male Female
Last Nam e First Name Birth Date Current school and track
G. EMERGENCY CONTACT INFORMATION
EMERGENCY CONTACT (other than parent(s)/leg al gua rdian (s) above)
1.
2.
3.
4.
Last Nam e First Name Home Telephone Number Cell/Pager Number Work Telephone Number
5.
6.
Relationship to student
Home Address: Number Street Apartment/Unit
City
Zip Code
EMERGENCY CONTACT (other than parent(s)/leg al gua rdian (s) above)
1.
2.
3.
4.
Last Nam e First Name Home Telephone Number Cell/Pager Number Work Telephone Number
5.
6.
Relationship to student
Home Address: Number Street Apartment/Unit
City
Zip Code
THE SCHOOL IS AUTH ORIZED TO RELEASE THIS STUDENT TO TH E FOLLOWING PERSONS IN NON-EMERGENCY SITUATIONS (after verifying with parent, in addition to the
emergency contacts above)
1.
Last Nam e First Name Home Telephone Number Relationship to Student Parent/legal guardian providing authorization
2.
Last Nam e First Name Home Telephone Number Relationship to Student Parent/legal guardian providing authorization
H. SIGNATURE
I verify that the information contained in this document is true and correct to the best of my knowledge.
X
Signature Date
Printed Name
Relationship to Student:
Parent
Legal Guardi an
Other (S p ec if y)
Page 3/3
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Student Enrollment Form - California PDF

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