2015 SECA ENROLLMENT FORM
Student ID No. ___________
STUDENT Full Name (Please Print):
Last ________________________________________________________, First ___________________________________, Middle __________________________
PERMANENT LEGAL ADDRESS:
Street Address __________________________
Home Phone:
, Apt. #______City __________________
Student Cell Phone: (_______) ____________________
(_______) _____________________
Birth Date: MM_______DD________YY________
ARE YOU HISPANIC/LATINO?
Age________
YES
Primary Ethnicity (Check ONE ONLY) :
ZIP: __________
Gender:
M
/
F
NO
White(5)
Black(4)
Hispanic(3)
Asian/Pacific Islander(2)
Native American/Alaska Native(1)
What is your race? (choose one or more):
WITH WHOM DO YOU LIVE?
____ Self
___ Father only
Black/African American
American Indian/Alaska Native
White
Native Hawaiian/Pacific Islander
Asian
____ Both Father & Mother
___ Mother only
Home Primary Language ___________
___ Father & Stepmother
___ Legal Guardian(s)
___ Foster Parents
___ Mother & Stepfather
___ Grandparents
Limited English Proficient: ___Yes ___No (LEP Start Date) __________
Student Birth Country ________________ If other than U.S., how many years in U.S. schools? __________
Migrant Education: Have you recently moved to this school district within the last 36 months for temporary or
seasonal agricultural or fishing work?
___ Yes
___No
Parent or Legal Guardian Name(s):
(Who live(s) at above LEGAL address)
Relationship ___________ Relationship__________
Last ___________________ Last ________________
First __________________ First ________________
Wk. Ph (___) ___________ Wk. Ph (___) _________
Cell Ph (___) ___________ Cell Ph (___) _________
E-mail: ________________ E-mail: _____________
______________________
___________________
If you live with someone other than legal guardian:
Relationship __________________________________
Last _____________________ First ______________
Last _____________________ First ______________
Street_______________________________________
City ___________________, MN Zip ___________
Home Phone (_____) __________________
Work Phone (_____) __________________
Cell Phone (_____) ____________________
EMERGENCY CONTACT NAME AND PHONE:
Special Education (IEP): ______ Yes ______ No
If “Yes” what school? ______________________________
____________________
Name
____________________
Phone
Graduation Standard Year: ____________
Grade ______ (based on graduation standard year)
Grade ______ (based on credits)
Office Use Only
504 Plan _____ Yes _____ No (Transportation Code 03)
Last School Attended:____________________
Date Left Mo./Yr.____________
Name of Counselor: ____________________________
SCHOOL 0618 or 0622 (CIRCLE)
Assessment Scheduled ___________________
Homebound
ALC Plus
PRIMARY IEP DISABILITY _______________
Enrollment Meeting Scheduled _________________
Projected Enroll Date: MM ____ DD____ YY____
HSGI Code: ________ FTE% _____