IRVINE UNIFIED SCHOOL DISTRICT
5050 Barranca Parkway · Irvine, CA 92604 · (949) 936-5000
THIS FORM MUST BE COMPLETED AND SIGNED FOR EACH CHILD AT EACH SCHOOL.
California law (Education Code Section 48200) and District Administrative Regulation 5111 require that a
student's parent(s) or legal guardian(s)
reside(s) (lives) within the Irvine Unified School District
.
--> I declare, under penalty of perjury under the laws of the State of California, that the answers I am providing below are true:
Parent/Guardian Signature Date
PART I: STUDENT AND PARENT/LEGAL GUARDIAN INFORMATION
Student's First Name Student's Last Name Grade Birth Date School
Parent/Legal Guardian's First Name Parent/ Legal Guardian's Last Name Parent/Legal Guardian's Phone Number
Parent/Legal Guardian's Current Street Address
Apt.
City
State ZIP
Parent Guardian Power of Attorney Caregiver
Please check one: This is a NEW address. This is NOT a new address.
SIBLINGS
Please list below the names of siblings who attend an IUSD school.
Student's First Name Student's Last Name Grade Birth Date School
Student's First Name Student's Last Name Grade Birth Date School
Student's First Name Student's Last Name Grade Birth Date School
PART II: READ EACH SENTENCE. INITIAL EACH BOX. DECLARATION OF UNDERSTANDING
My student resides
(lives)
with me 7 days a week at the address listed above, which is my primary residence.
I
agree to notify the school office, within 5 days, should my student, or I, move from this address.
I UNDERSTAND (INITIALS)
IUSD will actively investigate all cases where it has reason to believe false information has been provided on this
document or to any school/district official.
IUSD utilizes electronic residence verification services and employs residence verification staff to verify IUSD
district residency status, which may include home visits.
Student(s) may be disenrolled from his/her IUSD school
if investigations reveal
that students were enrolled on
the basis of providing false information, or are not living within the IUSD district.
FOR OFFICE USE ONLY
ERV DATE: _______________ ERV BATCH # ___________ INITIALS: __________ STANDARD RV PROCESS DATE: _________________ INITIALS: _____________
