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.
Specific Learning Disability
Deaf or Hard of Hearing
Other Health Impaired
Traumatic Brain Injured
Dual Sensory Impaired
Autism Spectrum Disorder
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 (____/____/_____)
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?
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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