2015-2016 STUDENT ENROLLMENT FORM
Failure to complete any part of this form will automatically disqualify your child for enrollment.
Student Information
Has your child ever attended LAUSD District public schools before?
Legal First Name
Male
Female
Legal Middle Name
Yes
No
Legal Last Name
Other Legal Name (if applicable)
Birth Date
Month (MM)
Birth City
Birth State
Day (DD)
Year (YYYY)
Birth Country
Physical Address
Apt #
Type of
Development Center
Residence
Foster Family Home or Kinship Placement
Hotels / Motels
Licensed Children’s Institution
City
Permanent Housing
Temporarily Unsheltered
Temporary Shelter
Other (please specify):
State and Zip
Mailing Address (if different than physical)
City
State and Zip
Apt #
Was the student born outside the U.S. but granted U.S. citizenship at the time of birth?
Student Ethnicity
Is this student Hispanic or Latino?
Primary Race
(No matter what ethnicity is
selected, at least one race must
also be selected)
Yes
No
Yes, Hispanic or Latino
No, not Hispanic or Latino
American Indian or Alaskan Native
Korean
Argentinean
Laotian
Asian Indian
Mexican American
Black or African American
Middle Eastern
Cambodian
Nicaraguan
Cuban
Other Asian
Declined to State
Other Pacific Islander
Dominican
Puerto Rican
Filipino
Salvadoran
Guamanian
Samoan
Hawaiian
Spaniard
Hispanic or Latino
Tahitian
Hmong
Vietnamese
Japanese
White
Student Enrollment Form
1
Student Name
Grade
Previous School / Enrollment Details
How will you be entering this school?
Previous School Type
(Choose one)
Enrolling for the first time in public school this year
Enrolling for the first time in California public school this year
Entering US from foreign country
Other:
Public school in the same district
Public school in a different district same state
Public school in a different state
Private, non-religiously-affiliated school in the same district
Private, non-religiously-affiliated school in a different district same state
Private, non-religiously-affiliated school in a different state
Private, religiously-affiliated school in the same district
Private, religiously-affiliated school in a different district same state
Private, religiously-affiliated school in a different state
Charter School
Home Schooling
Original Entry into US school (enrolling in school for first time ever, no previous school)
Original Entry to US school form a foreign country w/no schooling interruption
Original Entry into US school from a foreign country w/schooling interruption
Other
Previous School Address (Street, City, State, Zip)
Date first enrolled in US
Date first enrolled in this state
Date first enrolled in Kinder
Date first enrolled in the district
Grade first enrolled in the district
Grade first enrolled in school
Has the student ever received special education services and/or instruction?
Yes
No
Has the student ever had a 504 plan?
Yes
No
Family Information
Parent 1 First Name
Parent 1 Last Name
Parent 1 Email Address
Lives with student?
Yes
No
Physical Address (if different than student address)
Home Phone
Parent 2 First Name
Cell Phone
Parent 2 Last Name
Parent 2 Email Address
Lives with student?
Yes
No
Physical Address (if different than student address)
Home Phone
Cell Phone
Student Enrollment Form
2
Student Name
Grade
Education Level and Language Survey
Parent 1 Highest Level of Education
Parent 2 Highest Level of Education
Graduate Degree – Holds MA, MS, PhD or EdD
Graduate Degree – Holds MA, MS, PhD or EdD
College Graduate – Holds BA or BS
College Graduate – Holds BA or BS
Some College – AA, or 2 full years at 4 year University
Some College – AA, or 2 full years at 4 year University
High School Graduate – diploma, GED or HS Equivalency
High School Graduate – diploma, GED or HS Equivalency
Not a High School Graduate
Not a High School Graduate
Declined to State
Declined to State
Primary Language
Language the student first learned is spoken by the student, or in the case of student too
young to speak, the language spoken most frequently by adults in the home.
First Language
What language did the student first learn to speak?
Home Language
What language does the student most frequently read/speak at home?
Language Spoken by Parents to Student
What language does the parent/guardian most frequently speak to the student?
Language Spoken by Adults at Home
What language is most often spoken by adults in the home?
English Fluency
Is the student fluent in English?
Home Survey
Does this student have access to a computer at home?
Does this student have access to the internet at home?
How many times has the student’s family moved in the past
12 months?
Enrollment Enhancements & Modifiers
Student is allowed to use computers at school?
Yes
No
Is this student allowed to access internet at school?
Yes
No
Permission to include student information in the School Directory?
Yes
No
Grant permission to use pictures of the student for school purposes?
Yes
No
Grant permission to use pictures of the student in Yearbook & School Family Photos ONLY?
Yes
No
Grants permission to use student work produced by this student for school purposes?
Yes
No
I give permission for audio and video of my child made by the school to be used for school purposes.
Yes
No
Student Enrollment Form
3