MONTEREY PENINSULA UNIFIED SCHOOL
DISTRICT
Student Registration Form — Please Print Legibly in Blue or Black
Ink
Student Name Birth Date / /
Last Name First Name Middle Name Month Day Year
Other Name Used in School Birth City State Country
Male Female Grade Level Entering Middle or High School: Please provide transcript
Name and Address of last school attended:
City State Zip Code Country
Has your child been previously enrolled in a California school? No Yes If yes, what school? Year
Does your child receive Special Education Services? No Yes Is there a current IEP? No Yes (please attach) Is there a 504? No Yes
Has your child been previously expelled or suspended from school? No Yes Is your child currently suspended? No Yes
Has your child been previously retained? No Yes If yes, at what grade level?
Ethnicity: Is student Hispanic or Latino? Yes No
Student Race (required per US Federal Policy and CA Ed Code) — check all that apply :
American Indian or Alaskan Native Asian Indian Guamanian Hmong Samoan Filipino
Tribal
Affil
i
ati
on ___________________ Chinese Korean Laotian (Asian) Hawaiian Tahitian
Black or African American Japanese Vietnamese Cambodian Other Asian Other Pacific Islander
White
Home Language Survey
Date of Ini
ti
al Enrollment in US Schools / / Date of Ini
ti
al Enrollment in CA Schools / /
Month Day Year Month Day Year
Which language did your child learn first?
Which language does your child use most frequently at home?
Which language(s) is (are) spoken in your home?
Which language do you most frequently speak to your child?
If Spanish, how would you like your correspondence? Spanish English
Primary Home Address
Street City Zip Code
Is your home on (check one) U.S. govt. property POM (Ft. Ord) La Mesa Presidio No
Home Phone: Mailing Address (if different from above)
Parent/Legal Guardian
Relationship: Father Mother Legal Guardian
Step-parent
Lives With student?Yes No Military?Yes No Active?Yes No
DOD Civilian Employee Yes No Branch
Last Name:
First Name: Middle Initial
Contact Phone:
Parent/Legal Guardian
Relationship: Father Mother Legal Guardian Step-parent
Lives With student?Yes No Military?Yes No Active? Yes No
DOD Civilian Employee Yes No Branch
Last Name:
First Name: Middle Initial
Contact Phone:
Cell Phone Work Phone Cell Phone Work Phone
E-mail: E-mail:
Employer: Employer:
Employer Address: Employer Address:
Education Level: Not a high school graduate Education Level: Not a high school graduate
High school graduate High school graduate
Some college (includes AA degree) Some college (includes AA degree)
College graduate (BA or BS) College graduate (BA or BS)
Graduate school/postgraduate training Graduate school/postgraduate training
Address (if di
ffe
rent from above): Address (if di
ffe
rent from above):
AUTHORIZED
PARENT/GUARDIAN
SIGNATURE DATE
The Monterey Peninsula Unified School District is committed to equal opportunity for all individuals in education and in employment. MPUSD prohibits discrimination, harassment, intimidation, and bullying based on actual
or perceived age, ancestry, color, physical or mental disability, ethnicity, gender, gender expression, gender identity, genetic information, immigration status, marital status, medical information, national origin, parental
status, pregnancy status, race, religion, sex, sexual orientation, or association with a person or a group with one or more of these actual or perceived characteristics. If you believe you, or your student, have been subjected
to discrimination, harassment, intimidation, or bullying you should contact your school site principal and/or the following individuals at the MPUSD District Office at 700 Pacific Street, Monterey, CA 93940: Title IX Officer
and Title VI Officer: Dr. Manny Nunez, Assistant Superintendent, Human Resources (phone: 831-645-1272, email: mnunez@mpusd.net) or visit https://www.mpusd.net/titleix/ for more information. Title II Coordinator:
Katie Rivera, Senior Director, Special Education Services (phone: 831-645-1293, email: krivera@mpusd.net). Title V and 504 Coordinator: Donnie Everett, Assistant Superintendent, Multi-Tiered Systems of Support (phone:
831-645-1261, email: deverett@mpusd.net). Title 5 Officer: Ryan Altemeyer, Associate Superintendent, Business Services (phone: 831-645-1269, email: raltemeyer@mpusd.net).
School Use Only: Student # Entry Date
School Teacher
Student Enrollment Form 3565
Revised 4/17/20 MM
