Fillable Not Homeless Homeless* Completed MVA Packet (Hawaii DOE)

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Not Homeless Homeless* Completed MVA Packet (Hawaii DOE)

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  • 128 check-boxes
  • 157 other fields

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Legal Last Name: ________________________________ Gender: M F Grade Level: __________
Legal First Name: ________________________________ Birth Date: ___________________________
Middle Initial: __________ Suffix: (Jr, II, III, etc): ___________________________ Verification of DOB: ______________________________
Not Homeless Homeless* Completed MVA Packet
_____________________________________
DOE Representative Signature
_____________________________________
Parent/Legal Guardian Signature
*“Homeless” means individuals who lack a fixed, regular and adequate nighttime residence (within the meaning of section 42 USCS §11302(a)(1)) and
includes:
(i) children and youth who are
sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason; are living in
motels, hotels, trailer parks, or camping grounds due to the lack of alternative adequate accommodations; are living in emergency or transitional
shelters; are abandoned in hospitals; or are awaiting foster care placement.
(ii) children and youth who have a pr
imary nighttime residence that is a public or private place not designed for or ordinarily used as a regular
sleeping accommodation for human beings (within the meaning of 42 USCS §11302(a)(2)(C));
(iii) children and youth who are living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations or similar
settings; and
(iv) migratory chil
dren (as such term is defined in section 1309 of the Elementary and Secondary Education Act of 1965) who qualify as homeless for
the purposes of this subtitle.
If you have any questions regarding the above, please call 1-866-927-7095
Preschool Experience
Yes
No
If “Yes” – attended:
less than 6 months
Pre-School Program: (if applicable)
EOEL
between 6 and 12 months
more than 1 year
KALO
PDG
Country of Birth: _______________________________ If Country of Birth is other than US, give year of arrival: ____________________
US Citizen: Yes No
If not US Citizen, indicate status: Refugee Immigrant Non-Immigrant
Student ID No.
Entry Date
Entry Code
Room
School Name:
STUDENT ENROLLMENT FORM SIS-10W (Revised)
INSTRUCTIONS: PRINT YOUR ENTRIES LEGIBLY
CITIZENSHIP
Continue on next page
Page 1/4, SIS-10W Rev 12/16 SPAB
PRESCHOOL EXPERIENCE
Complex Area:
LAST HAWAII PUBLIC SCHOOL ATTENDED
Name:
Last Grade Attended: Year:
For school use only
STUDENT PERSONAL DATA
Ethnicity/Race Observed: _________ Initial _________ Date
PRIOR SCHOOL ATTENDED (If not Hawaii Public School)
LANGUAGE INFORMATION
Language Codes: (Select a letter from the list and fill in the blanks below)
Language (Spoken) at Home First (Acquired) Language Language Most Used
A – English F – Cebuano/Visayan K – Vietnamese Q – Fijian V – Pangasinan L – Other (Specify):
B – Cantonese G – Hawaiian M – Chuukese R – Hmong W – Portuguese ________
C – Mandarin H – Japanese N – Pohnpeian S – Lao X – Spanish
D – Ilocano I – Korean O – Cambodian T – Marshallese Y – Thai
E – Tagalog J – Samoan P – Chamorro U – Pampango Z - Tongan
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LEGAL PARENT/GUARDIAN LIVING IN THE HOUSEHOLD WITH STUDENT
PRIMARY ETHNICITY/RACE INFORMATION
I decline to provide ethnicity and race information. I understand that if I do not provide this information, a school representative will designate the
ethnicity and race categories for my child.
Does this person work for the Federal Government or work on Federal Property? Yes No
Are you (J) Hispanic (Ex. Cuban, Mexican, Puerto Rican, Spanish, Other Hispanic)? Yes No
Check all that apply:
A – American Indian or Alaska Native E – Native Hawaiian K – Samoan P – Tongan
B – Black G – Japanese L – White Q – Guamanian/Chamorro
C – Chinese H – Korean
N – Indo-Chinese (Ex. Cambodian,
Laotian, Vietnamese)
O – Micronesian (Ex. Chuukese,
Marshallese Pohnpeian,)
R – Other Asian
D – Filipino I – Portuguese S – Other Pacific Islander
Check one: Mr. Mrs. Ms. Other (specify): ______________________ Relation: ___________________________
Marital Status: Married Divorced Separated Single Custody of Child: Yes No
Custody Documentation Submitted: Yes No Custody Type: Sole Custody Physical Custody Joint Legal
________________________________________________ ______________________________________
Legal Last Name Legal First Name
Allow this person access to: (check all that apply) mailing portal (if applicable)
Home Address: _____________________________________________________ APT# ________ City ____________________ Zip ___________
Mailing Address (if different from Home Address): _______________________________________________________________________________
__________________________ __________________________ __________________________ __________________________
Home Phone # Cellular Phone # Pager # Work Phone # (include ext.)
Email Address: ___________________________________________________________________________________________________
messenger
EMERGENCY CONTACT: (check one) Call Sequence 1 2
Is this parent/guardian a member of the Armed Services, National Guard or Reserves? Yes No
Military Status (check one): Traditional Reservist / M-Day Active Duty (Title 10) Federal Technician (Title 32)
Deployed? Yes No
Branch of Service (check one):
Army Marine Air National Guard Navy Reserves
Air Force Coast Guard Army Reserves Marine Reserves
Navy
Army National Guard
Air Force Reserves
Coast Guard Reserves
Is
F
I
R
S
T
P
A
R
E
N
T
/
G
U
A
R
D
I
A
N
Continue on next page
Page 2/4, SIS-10W Rev 12/16 SPAB
ETHNICITY INFORMATION
What is the student’s primary race? (Select only ONE letter from either the ethnicity or race list and fill in the blank) ________
Please complete ETHNICITY INFORMATION, RACE INFORMATION, and PRIMARY ETHNICITY/RACE INFORMATION
RACE INFORMATION
LEGAL PARENT/GUARDIAN LIVING IN THE HOUSEHOLD WITH STUDENT
Check one: Mr. Mrs. ______________________ Relation: Ms. Other (specify): ___________________________
Marital Status: Married Divorced Separated Single Custody of Child: Yes No
Custody Documentation Submitted: Yes No Custody Type: Sole Custody Physical Custody Joint Legal
________________________________________________ ______________________________________
Legal Last Name Legal First Name
Home Address: ___________________________________________________ APT# ________ City ____________________ Zip ___________
Mailing Address (if different from Home Address): ____________________________________________________________________________
__________________________ __________________________ __________________________ __________________________
Home Phone # Cellular Phone # Pager # Work Phone # (include ext.)
Email Address: ___________________________________________________________________________________________________ Allow
this person access to: (check all that apply) mailing portal (if applicable) messenger
EMERGENCY CONTACT: (check one) Call Sequence 1 2
Is this parent/guardian a member of the Armed Services, National Guard or Reserves? Yes No
Military Status (check one): Traditional Reservist / M-Day Active Duty (Title 10) Federal Technician (Title 32)
Deployed? Yes No
Branch of Service (check one):
Army Marine Air National Guard Navy Reserves
Air Force Coast Guard Army Reserves Marine Reserves
Navy Army National Guard Air Force Reserves Coast Guard Reserves
Does this person work for the Federal Government or work on Federal Property? Yes No
Check one: Mr. Mrs. Ms. Other (specify): ______________________ Relation: __________________________
Marital Status: Married Divorced Separated Single Custody of Child: Yes No
________________________________________________ ______________________________________
Legal Last Name Legal First Name
Home Address: ___________________________________________________ APT# ________ City ____________________ Zip ___________
Mailing Address (if different from Home Address): ____________________________________________________________________________
__________________________ __________________________ __________________________ __________________________
Home Phone # Cellular Phone # Pager # Work Phone # (include ext.)
Email Address: ___________________________________________________________________________________________________ Allow
this person access to: (check all that apply) mailing portal (if applicable) messenger
EMERGENCY CONTACT: (check one) Sequence 1 2 3
S
E
C
O
N
D
P
A
R
E
N
T
/
G
U
A
R
D
I
A
N
P
A
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E
N
T
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G
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N
PARENT/GUARDIAN NOT LIVING WITH STUDENT
Continue on next page
Page 3/4, SIS-10W Rev 12/16 SPAB
Does this person work for the Federal Government or work on Federal Property? Yes No
FOR SCHOOL USE:
Is this parent/guardian a member of the Armed Services, National Guard or Reserves? Yes No
Military Status (check one): Traditional Reservist / M-Day Active Duty (Title 10) Federal Technician (Title 32)
Deployed? Yes No
Branch of Service (check one):
Army Marine Air National Guard Navy Reserves
Air Force Coast Guard Army Reserves Marine Reserves
Navy Army National Guard Air Force Reserves Coast Guard Reserves
(Person To Notify In Case Of Emergency Other than First or Second Parent/Guardian Contact)
Check one: Mr. Mrs. Ms. Other (specify): ______________________ Relation: ___________________________
______________________________________ ______________________________________ ____________________________________
Last Name First Name Email Address
__________________________ __________________________ __________________________ __________________________
Home Phone # Cellular Phone # Pager # Work Phone # (include ext.)
EMERGENCY CONTACT: (check one) Call Sequence 1 2 3 4 5
(Person To Notify In Case Of Emergency Other than First or Second Parent/Guardian Contact)
Check one:
Mr. Mrs. Ms. Other (specify): ______________________ Relation: ___________________________
______________________________________ ______________________________________ ____________________________________
Last Name First Name Email Address
__________________________ __________________________ __________________________ __________________________
Home Phone # Cellular Phone # Pager # Work Phone # (include ext.)
EMERGENCY CONTACT: (check one) Call Sequence 1 2 3 4 5
EMERGENCY CONTACT INFORMATION
S
E
C
O
N
D
F
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S
T
Parent/Legal Guardian Signature: Date:
Page 4/4, SIS-10W Rev 12/16 SPAB
SCHOOL SUPPLEMENTARY INFORMATION
Legal First, Middle Initial & Last
Name HIDOE School Attending DOB Grade Relationship
1.
2.
3.
4.
Other
Children
In
HIDOE
Schools:
LEGAL PARENT/GUARDIAN NOT LIVING WITH STUDENT (cont.)
G
U
A
R
D
I
A
N
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Not Homeless Homeless* Completed MVA Packet (Hawaii DOE)

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Completed 13 October 2021

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