Students
5111 F1a
Revised 7/16/09
Page 1 of 2
English
Dublin City School District
Student Enrollment Form
(Grades Kindergarten-5)
– Office Use Only –
Teacher: __________________________________ Entry Date: ___/___/___ Dublin Student I.D. No.: ____________
Homeroom No.: ________
Grade: ________
Student Name: _________________________
Last Name
Bus In: ________
_________________________
First Name
Bus Out: ________
_________________________
Middle Name
Address: _________________________________________________________________________________________
Street
City
Zip
Apartment No.: __________ or Lot No.: __________ Post Office Box: __________ Post Office Zip: _____________
Subdivision: _________________________________________________ County: _____________________________
Home Phone: _______________________________ Unlisted: ______ Check here if phone not yet connected: ______
Cell Phone: ______________________________________ Pager No.: ______________________________________
E-mail Address: ___________________________________________________________________________________
Student Social Security No.: _______-_____-_______
Sex: (M/F): __________
Birth Date: ______/______/______
Verified with: B = Birth Certificate
______
P = Passport
______
Place of Birth: __________________________________________________
R = Baptismal Record ______
City
State
Country
Parent(s) or Guardian(s) Name(s): _____________________________________________________________________
Father’s Full Name
Mother’s Full Name
Parent/Guardian Relationship: (Please check one of the following):
_____ One parent present (natural or adoptive)
_____ Living with Mother
_____ Living with Father
_____ Two parents present (natural, adoptive, or step)
_____ Living with Mother and Father
_____ Living with Mother and Stepfather
_____ Living with Father and Stepmother
_____ Legal Guardian
_____ Relative/Not Guardian
_____ Group Facility – Local ______________
_____ Group Facility – State _______________
_____ Independent
_____ Other
__________________________
Mother’s Maiden Name
List names and ages of brothers & sisters:
________________________________
________________________________
________________________________
________________________________
________________________________
OVER
Students
5111 F1a
Revised 7/16/09
Page 2 of 2
English
Student Enrollment Form (Grades Kindergarten-5)
Racial/Ethnic Group:
_____ W – White, Non-Hispanic
_____ B – Black, Non-Hispanic
_____ H – Hispanic
_____ A – Asian or Pacific Islander
_____ I – American Indian or Alaskan Native
_____ M – Multiracial
Citizenship Status:
_____ U.S. Citizen
_____ Exchange Student
_____ Other/Non-U.S. Citizen
If a student is from a foreign country, what date did he/she
enter the U.S. and from which country?
Date entered U.S.: __________________________
Country of origin: __________________________
1. What language did your son/daughter speak when he/she first learned to talk? _________________________________________
2. What language does your son/daughter use most frequently at home? _______________________________________________
3. What language do you use most frequently with your son/daughter? ________________________________________________
4. What language do the adults at home most often speak? __________________________________________________________
5. When did your son/daughter first enroll in school in the U.S.? Month ____________ Year ____________
If the answer to any of the first four questions above is a language other than English, please answer the following questions:
6. What language(s) does your son/daughter speak proficiently?
a. _________________________
b. _________________________
c. _________________________
7. When did your son/daughter start to learn English? (Including before arriving in the U.S.)
Month: ____________________
Year: ____________________
8. What school grades did your son/daughter complete outside the U.S.? (Circle all that apply.)
a. Pre-K
c. Grade 1
e. Grade 3
g. Grade 5
i. Grade 7
k. Grade 9
m. Grade 11
b. Kindergarten
d. Grade 2
f. Grade 4
h. Grade 6
j. Grade 8
l. Grade 10
n. Grade12
9. How many years of ESL instruction has your son/daughter received in the U.S.? ___________ (Number of years).
(Secretaries please note: If the answer to any of the first four questions above is a language other than English, please forward this
information to the district’s Data Processing Department and refer this student to the ESL teacher for LEP assessment.)
Has this child ever attended a Dublin School? Yes: _______
No: _______
If yes, what school(s) did he/she attend? __________________________________________ Years Attended: _________________
For KINDERGARTEN Enrollment Only – Please check the appropriate statements:
_____ My child has attended one year of preschool.
_____ My child has attended two or more years of preschool.
Name/Location of preschool(s) attended: ___________________________________________________________________
_____ My child has received child care in a day-care setting.
_____ My child has received child care in an at-home setting.
Please check ONLY if your child SHOULD BE receiving any of the following special services:
_____ Special Education (attach IEP)
_____ Speech Therapy
_____ Adaptive Physical Education
_____ Title I Math
_____ Occupational Therapy
_____ Title I Reading
_____ Physical Therapy
_____ Intervention (Reading)
_____ English as a Second Language (ESL)
_____ Gifted Education
Name and address of school previously attended prior to enrolling in Dublin City Schools:
___________________________________________________________________________________________________________
Daytime Parent/Guardian Phone Contacts
___________________________________________________________________________________________________________
Father’s Name
Father’s Occupation
Work Number
Place of Employment
___________________________________________________________________________________________________________
Mother’s Name
Mother’s Occupation
Work Number
Place of Employment
The foregoing information which I have supplied is true and correct.
_______________________________________________________________
Parent/Legal Guardian Signature
____________________________
Date