Independent School District 196
Rosemount-Apple Valley-Eagan Public Schools
Educating our students to reach their full potential
March 2016
501P
July 2000
Series Number_____________________
Adopted_________________________
Revised_________________________
Student and Census Information
Title _____________________________________________________________________________________________
Date _______________________ School #________________________ Student #______________________________ Family #_________________
PRINT AND COMPLETE ALL INFORMATION REQUESTED BELOW using black ink.
STUDENT Full Legal Name _______________________________________________________________________________________________
last name
first name
middle name
birthdate ________________________ sex _______ grade ________
For Federal reporting purposes
month/day/year
If left blank staff will complete.
Has student ever attended school in Minnesota?
Ethnicity (Check one):
Race (Check all that apply):
■ No ■ Yes - Where? ________________________________
■No, not Hispanic/Latino
■American Indian/Alaskan native
■Yes, Hispanic/Latino
■Asian
Which special service(s) has student received?
■ 504 Plan
■ ELL (English Language Learner)
■Black/African American
■ Special Ed (IEP) specify primary language
■Native Hawaiian or
■ Early Childhood __________________________
other Pacific Islander
■ Other ______________________
■ Gifted/Talented
■White
last school attended _________________________________________________________________________ District # ____________________
school address
(if other than District 196)
street
city
state
zip
Head of House (HOH) What relation is Head of House to student?
Please use Code from box below.
sex
Code
1st HOH ______________________________________________________________ ■ M ■ F
F = Father
G = Guardian
last first middle M = Mother
X = Self
2nd HOH ______________________________________________________________ ■ M ■ F
last
first middle P = Foster parent S = Step parent GP = Grandparent
O = Other ______________________
address_____________________________________________________________________________________ apt. # ______________________
city ____________________________________________________ state _______________
zip ______________________________________
If above address is temporary, please list permanent address and approximate date of possession:
street
city
state
zip
date
primary 1st HOH 2nd HOH
(
)
(
)
(
)
phone_______________________________
work phone______________________________
work phone_______________________________
1st HOH 2nd HOH
(
)
(
)
cell phone_______________________________
cell phone________________________________
1st HOH 2nd HOH
email address____________________________ email address_____________________________
List All children and adults living at this address other than those above: (List additional residents on separate sheet.)
Full Legal Name
first
middle
initial
sex
birthdate
mo/day/yr
school and grade
(if enrolled)
What relationship is
person to student?
______________________________________________________ ■ M ■ F _____________ ___________________
_________
______________________________________________________ ■ M ■ F _____________ ___________________
_________
______________________________________________________ ■ M ■ F _____________ ___________________
_________
Have you moved to this school district within the last 36 months for temporary or seasonal agricultural or fishing work?
X
___________________________________________________________________
parent/guardian signature
OFFICE USE
■ No
■ Yes
____________________________________
date
homeroom _____________________________ teacher/counselor _________________________________________________
■ re-enrolled
language code _____________ last location code _____________ start date _____________ Bus # _____________ Time _____________
■ birth certificate
■ guardianship papers received
■ transfer paperwork completed
Minnesota law requires the school district to keep accurate, updated records for all students. Failure to provide some or all of the requested information may limit the school district’s ability to enroll and
serve your student. This information will be used within the school district and may also be shared with the Minnesota Department of Education and as otherwise permitted by state and federal law. Some
of the information may be classified as directory (public) information.
C: Cumulative Folder, Student Information
Procedures/500 series/501P.indd/District 196 Graphics/3-31-16