Permit | VOR | CGA | HLS [CA_PrimaryLanguage]

Please Print Clearly with Black or Blue Ink

OFFICE USE ONLY Processed By: Date Completed: _______________________

Enrolling School: _______________________

Enrollment Date: _______________________

Student ID: ____________________________

STUDENT ENROLLMENT FORM

STUDENT INFORMATION

.

___________________________ ____________________________ _______________ _______________ __________________ Legal Last Name Legal First Name Middle Name Suffix(Jr., III, etc.) AKA/Nickname __________________________________________ _____________________ ______ _____________ (____)______________ Home Address (Street and Apt. #) City State Zip Primary Contact # _______ / _____________ ____________________________ __________________ _______________________ Grade Male / Female Birthdate Birth City Birth State/Province Birth Country (Needed Only for US, Canada, and Mexico)

FAMILY INFORMATION (NOT EMERGENCY CONTACT INFORMATION…………………………………………………... At above address student lives with:

Both Parents Father only Father and Stepmother Mother and Stepfather Other:____________________________

Mother only Foster Parents

Legal Guardian(s) Caregiver(s)

Circle One

FATHER/LEGAL GUARDIAN/CAREGIVER/OTHER:____________________ _____________________________________ (____)_____________ Last, First Primary Phone #

Home Work

Cell Other

(____)_____________ Secondary Phone #

Home Work

Cell Other

(____)_____________ Secondary Phone #

Home Work

Cell Other

Circle One

MOTHER/LEGAL GUARDIAN/CAREGIVER/OTHER:____________________ _____________________________________ (____)_____________ Last, First Primary Phone #

Home Work

Cell Other

Primary Contact (please check one only): Father/Legal Guardian/Caregiver Mother/Legal Guardian/Caregiver Preferred Parent’s Email Address (one only please):____________________________________________________________ Home Correspondence Language (used for district/school mailings): English Home Phone Language (used for phone calls home): English Cantonese

Chinese Mandarin

Spanish Spanish

Vietnamese Vietnamese

Family Living In: Permanent Housing Temporarily Unsheltered Converted Garage

Foster Family or Kinship Placement Temporary Shared Housing Hotel / Motel Temporary Shelter in Emergency or Foster Care Licensed Children’s Institution Other: ____________________________

STATE MANDATED INFORMATION (Required by the California State Department of Education) Hispanic or Latino (A person of Cuban, Mexican, Puerto Rican, South or What is your child’s ethnicity? (please check one) Central American, or other Spanish culture or origin, regardless of race)

Not Hispanic or Latino What is your child’s race? (Required for ALL students. Please check up to a maximum of five racial categories) __ American Indian or Alaska Native __ Black or African American __ White (A person having origins in any of the original peoples __ Filipino (A person having origins in any of the original peoples of of North, South, or Central America and maintains a Europe, the Middle East, or North Africa) __ Japanese tribal affiliation or community attachment) __ Hawaiian __ Vietnamese __ Chinese __ Samoan __ Laotian (From Laos) __ Korean __ Guamanian __ Cambodian __ Asian Indian __ Tahitian __ Other Asian __ Hmong __ Other Pacific Islander Have you or anyone in your family worked in agriculture, fishing, or food processing in the last three years? Yes No Has your child received Special Education services? RSP SDC Speech Other ______________ None Has your child received GATE services Yes No Does your child have a 504 Plan? Yes No Parent/Guardian Education Level (please check only the HIGHEST education level completed by either parent/guardian): Not a high school graduate Some college (includes AA degree) Graduate school/Post Graduate training High school graduate College graduate Declined to state or unknown When did your child first enroll in a United States K–12 school? (mm/dd/yy) _________________ Grade _________ When did your child first enroll in a California K–12 school?

(mm/dd/yy) _________________

Grade _________

OTHER CHILDREN LIVING IN THE HOME ___________________________________ _____________________ _____________ ____________________ __________ First and Last Name Relationship Birthdate Current School Grade ___________________________________ _____________________ _____________ ____________________ __________ First and Last Name Relationship Birthdate Current School Grade ___________________________________ _____________________ _____________ ____________________ __________ First and Last Name Relationship Birthdate Current School Grade ACADEMIC HISTORY Did your child attend pre-school?

Yes

No

If yes, which pre-school? ___________________________________

Has your child ever attended any of the following schools in Alhambra Unified? (please check all that apply) Moor Field Early Education Center Baldwin Brightwood Emery Park Fremont Garfield Granada

Marguerita Monterey Highlands Northrup Park Ramona Repetto Ynez

Alhambra High School Mark Keppel High School San Gabriel High School Century High School Independence High School

Date(s) enrolled ___________________________ Grade(s) attended ______________________________________ Has your child ever repeated a grade?

Yes

No If yes, grade repeated ________________________________

My child: is not under an expulsion order or recommended for expulsion from another school district. is currently under an expulsion order or has been recommended for expulsion from ________________ School District. Previous Schools Attended (please include the last three schools): ____________________________ _____________________ _____________________ Name of Last School School District City ____________________________ _____________________ _____________________ Name of Previous School School District City ____________________________ _____________________ _____________________ Name of Previous School School District City

Private School

_________________ State / Country _________________ State / Country _________________ State / Country

____________ Grade(s) ____________ Grade(s) ____________ Grade(s)

HOME LANGUAGE SURVEY (HOME LANGUAGE OF THE STUDENT) For each question, write the name(s) of the language(s) that apply in the space provided. Please do not leave any question unanswered. 1. Which language did your child learn when he/she first began to talk?

________________________________________

2. Which language does your child most frequently speak at home?

________________________________________

3. Which language do you (the parents or guardians) most frequently use when speaking with your child? 4. Which language is most often spoken by adults in the home? (parents, guardians, grandparents, or any other adults)

________________________________________ ________________________________________

Note: If previously enrolled in a CA school, Alhambra USD will reference previous district’s CELDT data and designation. “AUSD has the opportunity to receive federal Medicaid dollars for some health services performed at school. Do you consent to the secure release of limited education records to the Department of Health Care Services and our vendor, Paradigm, so that we can receive these dollars? Records that may be shared include: name and DOB; and health-related evaluation, intervention, and referral information.” ___________________________________________________ Parent / Legal Guardian / Caregiver Signature

______________________________ Date

My signature certifies that all information is accurate. In order to keep my child safe, I will report any changes of address, telephone, or emergency information to the school site within five days. ___________________________________________________ Parent / Legal Guardian / Caregiver Signature

______________________________ Date Form 3730 Rev. 120616