Lakeville Area Public Schools Student Enrollment Form Student Information Student Last Name: Birth Date:

First Name: Gender: Male Female

Middle Name:

Entering Grade:

Resident District (if not Lakeville Area Public Schools):

Nickname:

Start Date:

If not a resident of ISD194, has an Open Enrollment Agreement been completed and sent to Student Services? Yes

Early Childhood Screening is required for your child’s entry into public school kindergarten. Has your child

No

Yes No - In which District was your child screened?

completed screening (3-5 years old) with ISD194? Has your child previously attended a Minnesota School?

Yes - Name of District: _____________________________________________ No Year(s):

Has your child ever registered under a different name?

Yes - Previous name: No

Federal Designations * Home Primary Language (see information on reverse side) In order to help your *Racial/Ethnic Background of Student

child learn, your child’s teachers need to determine which language your student uses most. Please answer the following questions:

(Check ONLY one box): 

American Indian or Alaska Native



Asian or Pacific Islander



Hispanic



Black, not of Hispanic origin



White, not of Hispanic origin

Which language did your child learn first? English

Other (specify): ________________________________________

Which language is most often spoken in your home? English

Other (specify): ________________________________________

Which language does your child usually speak? English

Federal Race/Ethnicity categories required by No Child Left Behind. Complete Parts A and B: Part A – Check ONLY one:  No, not Hispanic/Latino  Yes, Hispanic/Latino Part B – Check ALL that apply:  American Indian or Alaska Native  Asian  Black or African American  Native Hawaiian or Other Pacific Islander  White

Other (specify): ________________________________________

Country of Birth: If born outside of USA: Date of entry to USA: ___________________________________________________________ Date of first enrollment in USA School: _________________________________________ Has this student completed three or more years of school in the USA? Yes No

Additional Student Information (Optional) Is this student:

Does your child receive any services in the following areas? Check all that apply:



Homeless

 Special Education - Individual Education Plan (IEP)



Ward of the State

 ADA Section 504 Plan



Immigrant

 Title-I



Foreign Exchange

 English Learner (EL)



Military-Connected

 Gifted/Talented

Youth

 Other__________________________________________________________________________________ Please Complete and Sign Back of Form  Lakeville Area Public Schools ISD #194 • Student Information Services • Revised 4.30.2015

Primary Household

Date Moved In:

Address:

City:

State: Zip:

Primary Household Adult 1 Last Name:

First Name:

Middle Name:

Relationship to Student:

Other Phone:

Male Female

Cell Work

Date of Birth:

E-mail Address:

Primary Household Adult 2 Last Name:

Gender:

First Name:

Middle Name:

Relationship to Student:

Home Phone:

Gender:

Other Phone:

Male Female

Cell Work

Date of Birth:

E-mail Address:

Other Children/Members in Primary Household Last Name:

First Name:

Middle Name: Gender: Relationship to Student: Birth Date: Male Female Male Female Male Female Male Female

Additional Household Address:

State:

Zip:

Middle Name:

Gender:

Other Phone:

Male Female

Cell Work

Additional Household Adult 1 Last Name:

First Name:

Relationship to Student:

Date of Birth: First Name:

Middle Name:

Relationship to Student:

Home Phone:

E-mail Address:

Additional Household Adult 2 Last Name:

Date Moved In:

City:

Date of Birth:

Gender:

Other Phone:

Male Female

Cell Work E-mail Address:

Other Children/Members in Additional Household Last Name:

First Name:

Middle Name: Gender: Relationship to Student: Birth Date:

Emergency Contacts (Other than those listed above) Name:

Work Phone:

Male Female Male Female Male Female Male Female

Cell Phone:

Home Phone:

Relationship to Student:

I hereby verify that the above information is true and correct to the best of my knowledge and belief. I understand that completing this form enrolls my student in the Lakeville Area Public Schools and grants permission to obtain all student records pertaining to my child.

Parent/Guardian Signature:

Date:

EXPLANATION OF PRIVATE INFORMATION REQUESTED ON THIS FORM In accordance with the Federal Data Privacy Act of 1974 and the State of Minnesota Privacy Law, you are not required to provide the information noted with an asterisk (*). There will be no adverse affect on you or your student if you do not choose to provide it. However, your cooperation in providing this information will ensure its accuracy and help to facilitate equitable educational opportunities for all students. Be assured that we will use the information in a manner that respects the privacy of our students and families. *Home Primary Language: In order to assist school districts to provide equal opportunity for a meaningful education to all students, Minnesota law requires that schools count and report the primary language of their students. * Racial/Ethnic Background: This information is needed to comply with state and federal reporting requirements relating to equity in education. Your cooperation in providing this information will ensure that we have accurate data on your child. Lakeville Area Public Schools ISD #194 • Student Information Services • Revised 4.30.2015

Lakeville Area Public Schools Student Enrollment Form

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