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First Name as on the Birth Certificate

Middle Name as on the Birth Certificate

Last Name as on the Birth Certificate

Suffix Select I II III IV Jr. Sr. V

Nick Name

Mothers Maiden Name (Ex: Smith)

Date of Birth (mm/dd/yyyy)

Birthplace City (ex: Columbus)

Age

Gender as listed on the Birth Certificate Select F - Female M - Male

Migrant Worker No Yes

Is the Student HomeLess ? * - Not Applicable A - Shelter B - Unsheltered C - Doubled-Up I - Hotel/Motel

Are You Hispanic Select * - Not Re-Collected N - No, the student is not Hispanic/Latino Y - Yes, the student is Hispanic/Latino

Race (check all that apply)

W-White

B-Black or African American

A-Asian

I-American Indian or Alaskan Native

P-Native Hawaiian or Other Pacific Islander

Military * - Not Applicable (Not a Military Student) A - Active Duty Force - Student is a dependent of a member of the Active Duty Forces B - National Guard - Student is a dependent of a member of the National Guard C - Reserve Duty

Mailing Address Same As Home Address Yes No

Mailing Street Address

Street Number

Street Name

City

Apartment

Lot

Other

State

Country

Zip Code

Subdivision

County

Phone Number Ex (999)999-9999

Type Select Cell Direct Dial Work Home Other Parent/Guardian Cell Phone Student Cell Phone TDA iPhone Work

Is Private ?