Manatee County School Enrollment Form
SCHOOL: _______________________________________________________________
Student Legal Name _________________________________________________________________________________ Grade Enrolling In ______
(As listed on Birth Certificate) Last Suffix (Jr, III, etc) First Middle
Any other legal name used _______________________________________________________________________________________________________
Residence address: _________________________________________________________________________________ Apt Bldg(specify)___________
_________________________________________________________________________________Home Phone (_____) ____________
City State Zip
Mailing address (if different): _____________________________________________________________________________________________________
Address Apt Bldg # City State Zip
Student resides at the above address with: *Other Out of Home/Foster Home* Father r Mothe Both Parents
____________________________________________________________________________________________________________________________________
*Explain (Appropriate guardianship documents MUST BE on file with School District)
_________________________________________________________________ /____________________________________________________________________
#1 Parent/Guardian e-mail address #2 Parent/Guardian e-mail address
Is student of Hispanic, Latino or Spanish origin? Yes No
Gender: Date of Birth (Month/Day/Year)____________/_________/_____________ FemaleMale
Birthplace: City___________________________________State_________Country_____________ Social Security# _______/______/_______
Verification office use ______ (Section 1008.386 F.S.)
Race: (Check all that apply but must check at least one)
White Black or African American Asian American Indian or Alaskan Native Native Hawaiian or Pacific Islander
Is student a child of a military family? Yes (if yes, specify below) No Residence On Base? Yes No
Active duty Medically discharged ___________ Death in the line of duty _________
Discharge date Date of death
Did you move to Manatee County as a result of a hurricane/earthquake? Hurricane _________________ Earthquake No
Did you move within Manatee County as a result of a hurricane/earthquake? Hurricane _____________Earthquake No
Emergency Contact/Pick-up List (Only parties marked Y below are allowed to pick up child in emergency and non-emergency situations.)
(“*AC=Automated contact. Parties marked Y will receive non-emergency communications)
Name
Relationship
to student
Pick-up
(Y/N)
*AC
(Y/N)
Place of Employment
Work Phone
Home Phone
Cell Phone
Enrolling Parent/Guardian
Parent/Other
Other
Other
Other
Other
Brothers/Sisters in Manatee County Schools (Public, Charter, Private)
Name: ___________________________________________________________ Grade _____________ School __________________________________________
Name: ___________________________________________________________ Grade ____________ School __________________________________________
Enrolling Parent Signature _________________________________________________________________________ Date_________________________
Print First Name_________________________________________________ Print Last Name_________________________________________________
Office use only Teacher __________________________
Entry code _____________Calendar __________________
ID#_______________________TEAM_________________
HR_________________CSL_________________________
Entry date: ________________Assignment code: _______
Transportation
Walk Bike Car Rider School Bus# _____ Day Care: Name____________________________________Phone____________
MIS41-00463 Office of Student Assignment PRC Approved 1/2020 Expires 1/2025
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Page 2 Manatee County School Enrollment Form Name ___________________________________________________ Grade ______
Last School Student Attended:
School Name _____________________________________________________________________________ County:_________________________
Street Address__________________________________________________________ Phone (_____) ____________________________________
City, State, Zip________________________________________________________ Fax (_____) _________________________________________
Has student ever attended a Manatee County school before? If so, name of school __________________________________________________
Has student ever attended another Florida School? If so, name of school/City/County _______________________________________________
Has student ever repeated a grade? If so, which grade(s)___________
Has your student ever been or is your student currently in any of the following programs? Check the appropriate boxes.
Gifted
Specific Learning Disability
Emotional/Behavioral Disability
Orthopedically Impaired
Deaf or Hard of Hearing
Other Health Impaired
504 Plan
ESOL
Speech Impaired
Language Impaired
Visually Impaired
Traumatic Brain Injured
Dual Sensory Impaired
Autism Spectrum Disorder
Developmentally Delayed
Intellectual Disability
Occupational Therapy
Physical Therapy
Alternative Ed
(specify)___________________
Florida Statute 1006.07(1)(b) requires that you provide the following information:
Has the student been expelled (not suspended) from a school? Yes No
Has the student had an arrest resulting in a charge? Yes No
Has the student been involved in the Juvenile Justice System? Yes No
Has the student ever been referred for mental health services? Yes No
If the answer is YES to any of the above, please explain:
The next three programs have opportunities available, if qualifications are met.
(MUST ANSWER) Home Language Survey If yes, what language?
1. Is a language other than English used in the home? Yes No___________________________________
2. Does the student have a first language other than English? Yes No___________________________________
3. Does the student most frequently speak a language other than English? Yes No___________________________________
Answering “yes” to one or more of the Home Language Survey questions will require your child to be screened for English language proficiency and may
result in his/her eligibility for ESOL services.
If answered “yes” to any one of these questions, please indicate date student entered school in the U.S. for the first time (____/____/_____)
(MUST ANSWER)
Has parent/guardian moved within the last three years from another county/state due to working in agriculture, fishing, or dairy activities? □Yes □No
Student Housing Questionnaire- Project HEART- McKinney Vento Application
This questionnaire is intended to address the McKinney-Vento Act 42 U.S.C. 11435. The answers to this housing information help determine the
services the student may be eligible to receive.
1. Is your current address a temporary living arrangement? Yes No
2. Is this temporary living arrangement due to loss of housing or economic hardship?
Yes No
If you answered YES to the above questions, please complete the remainder of this form. If you answered NO, you may stop here.
Where is the student presently living? (Check one box.)
In a motel/hotel
In an emergency shelter (Salvation Army, Hope or Family Resources)
With more than one family in a house or apartment (parent/guardian not on lease)
Moving from place to place
In a place not designed for ordinary sleeping accommodations such as a car, park, or campsite
Required: Enrolling parent must read, sign and date this section.
Pursuant to section 837.06, Fl Statutes (2008), whoever knowingly makes a false statement in writing with the intent to
mislead a public servant in the performance of his/her official duty shall be guilty of a misdemeanor of the second degree.
I hereby certify that I have custody of my child at least 50% of the time and that I have read all information on this form
and that all answers I have given are true and correct.
Enrolling Parent Signature _________________________________________________________________________ Date_________________________
Print First Name_________________________________________________ Print Last Name_________________________________________________
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