Fillable SAN DIEGO UNIFIED SCHOOL DISTRICT 2021-22 PreK-Grade 12 (School District of Indian River County)

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SAN DIEGO UNIFIED SCHOOL DISTRICT 2021-22 PreK-Grade 12 (School District of Indian River County)

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SAN DIEGO UNIFIED SCHOOL DISTRICT
2021-22 PreK-Grade 12 ENROLLMENT FORM
Complete Sections I-III and sign page 2. Section IV must be completed by office staff. Please print legibly using black or blue ink.
For full directions, please refer to
Directions for Completing the PreK-12 Enrollment Form
available at https://www.sandiegounified.org/enrollment-forms.
OFFICE ONLY
1. Student District ID:
OFFICE ONLY
2. Student State ID (SSID):
I. STUDENT INFORMATION
3. Last name (LEGAL NAME ONLY)
First
Middle
4. First Name on teacher rosters:
5. Former legal name(s) (optional):
6. Birthdate:
7. Gender ❑ Female ❑ Male
❑ Nonbinary
/ /
8. Is student Hispanic or
Latino/a/x?
❑ Yes ❑ No
9. Race: (check all boxes that apply)
❑ American Indian or Alaskan Native
❑ Black or African American
❑ Filipino
❑ White
Asian/ Indochinese
❑ Asian Indian ❑ Cambodian ❑ Chinese
❑ Hmong ❑ Japanese ❑ Korean
❑ Laotian ❑ Vietnamese ❑ Other Asian
Pacific Islander
❑ Guamanian ❑ Hawaiian
❑ Samoan ❑ Tahitian
❑ Other Pacific Islander
10. Release of Information: Directory-type information may be shared with individuals and organizations
authorized to receive this type of information unless it is prohibited by the parent/guardian. See the
district’s Facts for Parents for the individuals and organizations, and the student information that may be
released. If you do not want the information shared, you must select “Opt Out.” ❑ Opt Out
11a. Student email
address (optional):
11b. Student phone
(optional):
( )
12. Household address:
City, State:
ZIP Code:
13. Primary phone:
( )
14. Mailing address (if different from household):
City, State:
ZIP Code:
15. City, State, Country of birth:
16. First enrolled in US Preschool:
Date: / /
17a. First enrolled in a CA school
(TK-12): Date: / /
17b. First enrolled in a US school
(TK-12): Date: / /
18. Current Caregiver (check one): ❑ Parent/legal guardian ❑ Other adult (not legal guardian, requires Caregiver Affidavit)
19a. Foster Living Situation:
Check one if applicable:
❑ Family Home (FFH) ❑ Group Home (FGH) (FFA)
❑ Formal Kinship Care (including NREFM) ❑ Tribal Foster Care
19b.Temporary/inadequate residence due to financial hardship:
Check all that apply:
❑ Living with someone/Doubling up ❑ Unaccompanied Youth
❑ Hotel/motel ❑ Sheltered ❑ Unsheltered ❑ Runaway Youth
20. Other Living Situation: ❑ International Exchange ❑ Residential facility ❑ Hospital (not state hospital) ❑ ___________________________
21. Complete and include all minors under 18 years of age who live in the same household (siblings and non-siblings), even if not enrolled in San Diego
Unified. If additional space is needed, use “Notes” in Section IV on back of form.
Full name:
Birthdate:
School name:
Relationship to student:
Full name:
Birthdate:
School name:
Relationship to student:
Full name:
Birthdate:
School name:
Relationship to student:
II. CONTACT INFORMATION Provide at least three contacts—if additional space is needed use “Notes” in Section IV on back of form.
22. Parent/Guardian/Contact
23. Parent/Guardian/Contact
24. Emergency Contacts
(other than already listed)
Full name
Full name:
Relationship to student
Lives with student?
❑ Yes ❑ No
If no, provide address here:
___________________________
___________________________
❑ Yes ❑ No
If no, provide address here:
____________________________
____________________________
Relationship to student:
Home phone ( )
Work phone ( )
Cell Phone ( )
Home phone
( )
( )
Email address:
Work phone
( )
( )
Primary language:
Cell phone
( )
( )
❑ Interpreter required
Email address
❑ OK to release student
Employer
Military (check all that
apply)
❑ Active Duty
❑ DOD Employee
❑ Reserves
National Guard ❑ Full Time ❑ Part Time
❑ Active Duty
❑ DOD Employee
❑ Reserves
National Guard ❑ Full Time ❑ Part Time
Full name:
Relationship to student:
Primary language
Home phone ( )
Education level
(select one)
❑ Not a High School Graduate
❑ High School Graduate
❑ Some College/AA Degree
❑ College Graduate
❑ Graduate School/Post-Graduate
❑ Decline to state
❑ Not a High School Graduate
❑ High School Graduate
❑ Some College/AA Degree
❑ College Graduate
❑ Graduate School/Post-Graduate
❑ Decline to state
Work phone ( )
Cell Phone ( )
Email address:
Primary language:
❑ Interpreter required
Additional information
Report card & Progress report provided
❑ Interpreter required
❑ Access to student info online
❑ Report card ❑ Progress report
❑ Interpreter required
❑ Access to student info online
❑ OK to release student
SIGNATURE REQUIRED ON REVERSE
OFFICE ONLY
Student Name: _____________________________________________ Grade:________ Teacher: ____________________________ Room #: _________
III. QUESTIONS FOR PARENT/GUARDIAN
The following questions provide important information for the school staff. Parents must review the following questions. Check “Yes” or “No” for each question
where appropriate. Questions 28, 30 & 31 require that you check “Opt Out” or leave blank if you agree to your student’s participation.
25a. Has your student ever received
Special Education services?
25b. Does your student have a 504 Plan?
❑ Yes ❑ No
❑ Yes ❑ No
26. Has one of the parents/guardians engaged in migrant work (moved and
worked seasonally in jobs related to agriculture, lumber or fishery) in the past
three years?
❑ Yes ❑ No
27. Name, city, and state/country of last school attended:
______________________________________________________
______________________________________________________
______________________________________________________
Last grade level completed: ________
28. (For students in Grades 7, 9, & 11) The district would like your
student to participate in the California Healthy Kids Survey (CHKS). The
survey is anonymous and confidential. If you do not want your student to
participate, you must select “Opt Out.”
❑ Opt Out
29. (High school students only) Has your student ever played
interscholastic athletics?
❑ Yes ❑ No
30. (Grade 12 only) The district is required to submit a Cal Grant high school GPA to the California Student Aid Commission (CSAC) for all
graduating seniors unless the parent opts out of the submission process. The GPA will be submitted electronically by October 1 of each year unless
you select “Opt Out,” or submit an Opt Out form. https://mygrantinfo.csac.ca.gov/
❑ Opt Out
31. (High school only) Federal law requires release of student information to military recruiters. If you do NOT want this information released
for your student, you must select “Opt Out.” http://www2.ed.gov/policy/gen/guid/fpco/hottopics/ht-10-09-02a.html
❑ Opt Out
32. (High school only) Parents may authorize their student’s school to release educational information including:
a. Transcripts, Letters of Recommendation, Financial Aid Forms, Report Cards, and Class Ranking Status including UC ELC data
b. Disciplinary Records
By checking “Yes” I give permission to State/Federal Financial Aid Programs/Scholarship Programs/Private Schools/University/College personnel
and their authorized agents to access my student’s educational records.
Special Education and medical information will not be released without
additional consent (a separate form will need to be submitted).
❑ Yes ❑ No
❑ Yes ❑ No
33. LEA Medi-Cal Billing Options Program: (Medi-Cal reimbursements support student services. Details on LEA Medical-Cal see
Facts for Parents
Section F)
☐ I consent to the release of my child’s related health records for Medi-Cal billing purposes. This will not affect my Medi-Cal benefits.
☐ I do not consent to the release of my child’s related health records for Medi-Cal billing purposes
The information provided in Sections I-III is true to the best of my knowledge.
Parent/Guardian/Contact signature (required)
Date
IV. DISTRICT ADMINISTRATIVE INFORMATION – FOR OFFICE USE ONLY
34. Address verification document:
36. Neighborhood school: ______________________________
38. District of residence: ___________________________
❑ Interdistrict Attendance Permit ❑ InterSELPA agreement
40. Immunization status: ❑ Complete ❑ Incomplete
❑ Conditional ❑ Exempt - District Nurse Approval Required
35. Date address verified: / /
37. Birth verification documents:
❑ Birth certificate ❑ Affidavit ❑ Church records ❑ Passport
❑ School records ❑ Unverified
39. Boundary exception for non-resident student __
41a. (K only) Dental Exam? ❑ Yes ❑ No
41b. (K only) Physical Exam? ❑ Yes ❑ No
ENTRY INFORMATION
42. Previously enrolled in San Diego Unified? ❑ Yes* ❑ No
*If Yes: Last year enrolled_______________ School______________________________________ Grade___________
43. Entry date: ______ / ______ / _____
44. Entry reason (check one):
❑ Enter from within San Diego Unified ❑ Enter from Out of District ❑ Initial Enrollment-Preschool ❑ Enter from Out of State
❑ Initial Enrollment TK-12 ❑ Preschool Enroll-Not Initial ❑ Enter from Charter School within San Diego Unified
45. For students new to San Diego Unified entering from
within California:
Student State ID (SSID) (if known): ______________________
Previous CA district: ___________________________________
Previous CA school name: ______________________________
46. For students new to San Diego Unified entering from outside of California:
Previous school name: _________________________________________________
City, State/Country: ___________________________________________________
NOTES/ADDITIONAL INFORMATION/LEGAL BINDINGS
SAN DIEGO UNIFIED SCHOOL DISTRICT 2021-22 PreK–Grade 12 ENROLLMENT FORM rev 2.5.2021_eh
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SAN DIEGO UNIFIED SCHOOL DISTRICT 2021-22 PreK-Grade 12 (School District of Indian River County)

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Completed 24 August 2021

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