Students Last Name First Name
Grade 2006/2007 4 5 6 7 8 9 10 11 12 Date of Birth (MO/DAY/YEAR) Gender Male Female

Mailing Address City Zip Code

Place of Birth: City State

Ethnic Choice: Select the option you most closely identify with:
White (Not Hispanic Orgin) Hispanic (Mexican or Hispanic Orgin) Native American Indian or Alaskin Indian Other

Last School Attended Last Attendance {MO/DAY/YEAR} Location
City State Zip Telephone
Has student ever been in a Special Education Program? No Yes Type of Program or Service
Student lives with Parents Mother Father Foster or Group Home Other

What was the first language student learned to speak? What language is spoken often at home?
If Bilingual and/or English as a second language instruction is recommended, I want my child to participate Yes No

NAME Email Address
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