Complete Registration

STUDENT INFORMATION

First Name

Middle Name

Last Name

Suffix

Nick Name

Mothers Maiden Name (Ex: Smith)

Date of Birth (mm/dd/yyyy)

Birthplace City (Ex: Columbus)

Age

Gender

Migrant Worker

Is the student homeless?

Are You Hispanic

Race (check that all apply)

W-White

B-Black or African American

A-Asian

I-American Indian or Alaskan Native

P-Native Hawaiian or Other Pacific Islander

Military

Student Physical Address

Street Number

Street Name

City

Apartment

Lot

Other

State

Zip Code

County

Country

Subdivision

Alternate Address

Street Number

Street Name

City

Apartment

Lot

Other

State

Zip Code

County

Country

Subdivision

Mailing Address Same As Home Address

Mailing Street Address

Street Number

Street Name

City

Apartment

Lot

Other

State

Zip Code

County

Country

Subdivision

Phone Number Ex (999)999-9999

Type

Is Private ?

Alternate Phone Number Ex (999)999-9999

Type

Is Private ?

Contacts

Child Lives With

Contact Information

Prefix

Suffix

Contact First Name

Contact Middle Name

Contact Last Name

Contact Relationship with Student

Is the contact legal custodian of the student

Is the contact legal guardian of the student

Address same as student address

Priority Order

Street Address

Street Number

Street Name

Contact City

Contact Apartment

Contact Lot

Contact Other

Contact State

Contact Zip Code

Contact County

Contact Country

Contact Subdivision

Email Type

Email Address

Phone Same as Student Phone

Contact Phone Number (999)999-9999

Type

Ext

Is Private ?

Contact Alternate Phone Number (999)999-9999

Type

Ext

Is Private ?

Prefix

Suffix

Secondary Contact FirstName

Secondary Contact MiddleName

Secondary Contact LastName

Secondary Contact Relationship With Student

Is the contact the legal custodian of the student ?

Is the contact the legal guardian of the student ?

Secondary Address Same As Student Address

Legal Guardian Contact Order

Street Address

Street Number

Street Name

Contact City

Contact Apartment

Contact Lot

Contact Other

Contact State

Contact Zip Code

Contact County

Contact Country

Contact Subdivision

Email Type

Email Address

Secondary Contact Phone As Student Phone

Secondary Contact Phone Number Ex (999)999-9999)

Type

Ext

Is Private ?

Secondary Contact Alternate Phone Number Ex (999)999-9999)

Type

Ext

Is Private ?

School Info

School District Of Residence

Former School District

Former School Attended

Former School Type

Currently Enrolled In School

Is the Student Currently Expelled?

Reason Not Enrolled Previously

Last grade completed ?

Current Grade Level

Year Entered 9th Grade

Tested Gifted/Talented

Student has GIEP (Gifted Individualized Education Program)

Has student been identified as having a disability? (AKA - IEP)

Has student been identified as having a disability under Section 504?

Has the student been identified as Limited English Proficient?

What is the student's native language?

What is the language spoken at home?

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Technology

Does the student need a PC Package?

Does the student need a printer?

Do you currently have a internet service at home?

What type of internet service do you currently have?

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Survey Questions

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