Fillable LOS ANGELES UNIFIED SCHOOL DISTRICT STUDENT ENROLLMENT FORM (Los Angeles Unified School District)

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LOS ANGELES UNIFIED SCHOOL DISTRICT STUDENT ENROLLMENT FORM (Los Angeles Unified School District)

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Student Name:
Date of Birth:
Office Use Only
1.
6.
LAUSD / STATE STUDENT ID NUMBER:
2.
LOCATION CODE:
7.
HOUSEHOLD NUMBER:
3.
TRACK/SLC:
8.
HOMEROOM:
4.
ENROLLMENT DATE/CODE:
9.
TEACHER/COUNSELOR:
5.
STUDENT ENTRY GRADE LEVEL:
10.
ENROLLMENT WIZARD USED:
Yes
No
LOS ANGELES UNIFIED SCHOOL DISTRICT
STUDENT ENROLLMENT FORM
INSTRUCTIONS: Please print using black or blue ink. If you have any questions, please ask for assistance.
A. STUDENT INFORMATION
(LAUSDMAX: Family Member Information)
1.
2.
Legal Name: Last
First
Middle
Alias/Nickname: Last
First
Middle
3.
4.
Home Address: Number
Street
Apt./Unit
City
Zip Code
Home Telephone Number
5.
Sex: Male
6.
7.
Female
Date of Birth
Place of Birth: City
State/Province
Country
B. PARENT/LEGAL GUARDIAN WITH WHOM THE STUDENT LIVES
(LAUSDMAX: Caretaker Information)
1.
2.
Legal Name: Last
First
Middle
Other Names Used: Last
First
Middle
3.
4.
5.
Day
6.
Home Telephone Number Cell/Pager Number Work Telephone Number
Evening
Email Address
7.
Home Correspondence Language Correspondence is provided in the following languages; select preferred language.
If Other is indicated, written correspondence will be in English.
English Spanish Armenian Chinese Farsi Filipino Korean Russian Vietnamese Other:
8.
Highest Level of Education Completed
Not a High School Graduate
High School Graduate or Equivalent
Some College (includes AA Degree)
College Graduate
Graduate School/Post Graduate Training
Decline to State or Unknown
9.
Does the student live with this parent/legal guardian?
Yes No
10.
Relationship to Student:
C. HOME LANGUAGE AND ETHNICITY INFORMATION
1.
Home Language of the Student
A.
Which language did this student learn when he/she first began to talk?
B.
Which language does this student most frequently use at home?
C.
Which language do you use most frequently to speak to this student?
D.
Which language is most often used by the adults at home?
E.
Has this student received any formal English language instruction (listening, speaking, reading, or writing)?
Yes No
2.
Is the student’s ethnicity Hispanic/Latino?
Yes No
3.
Student’s Primary Race (Mark one choice)
African American or Black
American Indian or Alaska Native
White
Asian:
Asian Indian
Cambodian
Chinese
Filipino
Hmong
Japanese
Korean
Laotian
Vietnamese
Other Asian
Pacific Islander: Guamanian Native Hawaiian Samoan Tahitian Other Pacific Islander
4.
Student’s Additional Race (Optional)
African American or Black
American Indian or Alaska Native
White
Asian:
Asian Indian
Cambodian
Chinese
Filipino
Hmong
Japanese
Korean
Laotian
Vietnamese
Other Asian
Pacific Islander:
Guamanian
Native Hawaiian
Samoan
Tahitian
Other Pacific Islander
D. STUDENT EDUCATIONAL INFORMATION
1.
Special Services
If you have any questions regarding this section, please refer to the brochure entitled “Are You Puzzled By Your Child’s Special Needs?”
A.
Was this student receiving special education services at his/her previous school?
Yes No
B.
Did this student have a current Individualized Education Program (IEP) at the previous school?
Yes No
If Yes, do you have a copy of the student’s IEP with you?
Yes No
C.
Did this student have a Section 504 Plan at his/her previous school?
Yes No
If Yes, do you have a copy of the student’s Section 504 Plan with you?
Yes No
D.
Does the student have difficulties that interfere with his/her ability to go to school or to learn?
Yes No
E.
Has this student been identified for gifted and talented educational services (GATE)?
Yes No
2.
Previous School Information
A.
Has this student previously attended this school?
Yes No
If
Yes
, when?
B.
Has this student previously attended any other school or center in the LAUSD (e.g., early education center, state preschool, SRLDP, Head Start, or other preschool)
Yes No
If Yes, list most recent school/center attended.
Name of School
City/State
Dates Attended
Grade Level(s)
C.
Please list last non-LAUSD school student attended (including early education center, state preschool, SRLDP, Head Start, faith based or other preschool):
Name of School
City/State
Type of School
Dates Attended
Grade Level(s)
Student Name:
Date of Birth:
LOS ANGELES UNIFIED SCHOOL DISTRICT
STUDENT ENROLLMENT FORM
D. STUDENT EDUCATIONAL INFORMATION (Continued)
D.
Did you attempt to enroll the child in a different school in Los Angeles County for the current or preceding year?
Yes No
If No, skip to E.
1.
If
Yes
, what was the outcome?
Accepted Denied Wait Listed Other
2.
Please provide name of school:
E.
Is student currently under an expulsion order?
Yes No
If Yes, please list the name of the school district
F. Date of first U.S. school enrollment excluding preschool (mm/dd/yy)
G.
Date of first California school enrollment excluding preschool (mm/dd/yy)
E. ADDITIONAL HOUSEHOLD INFORMATION
1.
Court Orders
A.
Are there any court orders you wish to notify the school about regarding legal custody, physical custody or restricted contact with the school or child?
Yes No
If Yes, a copy of the court order must be provided to the school.
2.
Student Lives with Foster Family
Yes No
If Yes,
Relative Caregiver
If Yes, please provide Notification of Placement Status Form
Non-Relative Caregiver
Children’s Social Worker (CSW) Telephone Number (ext)
3.
Complete these three rows if student’s address is a licensed children’s institution/family foster agency/group home/adult residential facility.
A.
B.
C.
D.
Facility Name Facility Type License Number Contact Person
E.
F.
G.
Facility Telephone Number
Alternate Telephone Number
Facility Street Address: Number
Street
Apt./Unit
City
Zip Code
H.
I.
Children’s Social Worker (CSW)
Telephone Number & ext.
4.
Does the student have any relatives who are all or part American Indian or Alaska Native?
Yes No
5.
Has the student’s parent or legal guardian worked in one or more of the following industries in the last three years (agriculture, dairy, fishery, food
processing/packing, or livestock)? If you respond Yes, you will be contacted at home regarding the Migrant Education Program and whether your child
may qualify for its free academic assistance and health benefits.
Yes No
F. ADDITIONAL FAMILY INFORMATION
(LAUSDMAX: Caretaker Information)
PARENT/LEGAL GUARDIAN/CAREGIVER:
1.
2.
Legal Name: Last
First
Middle
Other Names Used
3.
Home Address (if different than student’s) Number Street Apt/Unit City Zip Code
4.
5.
6.
Day
7.
Home Telephone Number
Cell/Pager Number
Work Telephone Number
Evening
E-mail Address
8.
Preferred Correspondence Language
English
Spanish
Armenian
Chinese
Farsi
Filipino
Korean
Russian
Vietnamese
9.
Highest Level of Education Completed
Not a High School Graduate
High School Graduate or Equivalent
Some College (includes AA Degree)
College Graduate
Graduate School/Post Graduate Training
Decline to State or Unknown
10.
Does the student live with this individual?
Yes No
11.
Relationship to Student:
PARENT/LEGAL GUARDIAN/CAREGIVER:
1.
2.
Legal Name: Last
First
Middle
Other Names Used
3.
Home Address (if different than student’s) Number Street Apt/Unit City Zip Code
4.
5.
6.
Day
7.
Home Telephone Number
Cell/Pager Number
Work Telephone Number
Evening
E-mail Address
8.
Preferred Correspondence Language
English
Spanish
Armenian
Chinese
Farsi
Filipino
Korean
Russian
Vietnamese
9.
Highest Level of Education Completed
Not a High School Graduate
High School Graduate or Equivalent
Some College (includes AA Degree)
College Graduate
Graduate School/Post Graduate Training
Decline to State or Unknown
10.
Does the student live with this individual?
Yes No
11.
Relationship to Student:
Student Name:
Date of Birth:
LOS ANGELES UNIFIED SCHOOL DISTRICT
STUDENT ENROLLMENT FORM
F. ADDITIONAL FAMILY INFORMATION (Continued)
(LAUSDMAX: Caretaker Information)
PARENT/LEGAL GUARDIAN/CAREGIVER:
1.
2.
Legal Name: Last
First
Middle
Other Names Used
3.
Home Address (if different than student’s) Number
Street
Apt/Unit
City
Zip Code
4.
5.
6.
Day
7.
Home Telephone Number Cell/Pager Number Work Telephone Number Evening E-mail Address
8.
Preferred Correspondence Language
English
Spanish
Armenian
Chinese
Farsi
Filipino
Korean
Russian
Vietnamese
9.
Highest Level of Education Completed
Not a High School Graduate
High School Graduate or Equivalent
Some College (includes AA Degree)
College Graduate
Graduate School/Post Graduate Training
Decline to State or Unknown
10.
Does the student live with this individual?
Yes No
11.
Relationship to Student:
ADDITIONAL SCHOOL AGE CHILDREN LIVING IN HOUSEHOLD WITH SAME PARENT(S)/LEGAL GUARDIAN(S) (include brothers, sisters, and cousins)
1.
Sex:
Male Female
Last Name
First Name
Birth Date
Current school and track
2.
Sex:
Male Female
Last Name
First Name
Birth Date
Current school and track
3. Sex: Male Female
Last Name
First Name
Birth Date
Current school and track
4. Sex: Male Female
Last Name First Name Birth Date Current school and track
5. Sex: Male Female
Last Name First Name Birth Date Current school and track
6. Sex: Male Female
Last Name First Name Birth Date Current school and track
G. EMERGENCY CONTACT INFORMATION
EMERGENCY CONTACT (other than parent(s)/legal guardian(s) above)
1.
2.
3.
4.
Last Name First Name Home Telephone Number Cell/Pager Number Work Telephone Number
5.
6.
Relationship to student
Home Address: Number Street Apartment/Unit
City
Zip Code
EMERGENCY CONTACT (other than parent(s)/legal guardian(s) above)
1.
2.
3.
4.
Last Name First Name Home Telephone Number Cell/Pager Number Work Telephone Number
5.
6.
Relationship to student
Home Address: Number Street Apartment/Unit
City
Zip Code
THE SCHOOL IS AUTHORIZED TO RELEASE THIS STUDENT TO THE FOLLOWING PERSONS IN NON-EMERGENCY SITUATIONS (after verifying with parent, in addition to the
emergency contacts above)
1.
Last Name First Name Home Telephone Number Relationship to Student Parent/legal guardian providing authorization
2.
Last Name First Name Home Telephone Number Relationship to Student Parent/legal guardian providing authorization
H. SIGNATURE
I verify that the information contained in this document is true and correct to the best of my knowledge.
X
Signature Date
Printed Name
Relationship to Student:
Parent
Legal Guardian
Other (Specify)
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Completed 18 August 2020

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