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PORTLAND PUBLIC SCHOOLS
STUDENT REGISTRATION FORM
Revision Date: May 18, 2020
Español (503) 916-3582 | Tiếng Việt (503) 916-3584 |
中文
(503) 916-3585 | Soomaali (503) 916-3586 | Русский (503) 916-3583
Instructions: Please print using a black ballpoint pen, complete all pages and sign and date the last page.
Notify your school immediately if any of your information changes. If you need help filling out this form, please
contact your school.
STUDENT INFORMATION
1. Legal Last Name ___________________________________ 2. Legal First Name ____________________________________
3. Legal Middle ________________________________ 4. Grade _________ 5. Gender:
Female Male Non-Binary
6. Preferred Last Name _______________________________ 7. Preferred First Name ________________________________
8. Birthdate ________________________________________________________________________________________________
9. Place of Birth:
US and territories (Puerto Rico, Guam, Northern Mariana Islands, United States Virgin Islands, American Samoa)
Outside of US
LANGUAGE USE SURVEY
Per Oregon Law: If a language other than English is indicated, your student will be referred for English language
assessment to determine if they qualify for ESL services. Other responses may be used to determine if your student
qualifies for assessment.
10. What language(s) does your child hear or use regularly in your household (i.e., spoken, media, music,
literature, etc.)?
Hear: __________________________________________________________________________________________________
Use (i.e., American Sign Language (ASL)): _________________________________________________________________
11. Describe the language(s) your child understands.
No English
Mostly another language and a little English
English and another language equally
Mostly English and a little of another language
Tribal/Heritage/Native Language
(i.e., languages spoken by American Indian/Alaska,
Native Hawaiians, and citizens of U.S. Territories)
Only English
12. What language(s) does your child CURRENTLY speak/express most frequently outside of school?
________________________________________________________________________________________________________
13. Does your child frequently participate in cultural activities that are in a language other than English? Please list the
activity and how often your child participates in the activity (e.g., once/week, 2 times/week, once a month, etc.).
________________________________________________________________________________________________________
14. Is there anything else you think the school should know about your child’s language use (e.g., what language did
your child speak/express from ages 0–4; did your child have speech classes; did your child attend a bilingual pre-
school, etc.)?
________________________________________________________________________________________________________
Revision
Date: May 18, 2020
2
Student Name ____________________________________________
Student ID #___________________________________________________
School ______________________________________________
Grade ________ Homeroom __________________________
Official use only
LANGUAGE USE SURVEY (CONTINUED)
15. What language(s) do adults most frequently use when speaking/conversing to your child?
Parent/Guardian: __________________________________ Parent/Guardian: __________________________________
Other Adults in the Home: _________________________ Childcare Providers: _______________________________
An English Learner is defined as a student:
• Who was not born in the United States or whose native language is a language other than English
• Whose native language is a language other than English, and who comes from an environment where a
language other than English is dominant
• Whose difficulties in speaking, reading, writing, or understanding the English language may impact the
student’s ability to successfully achieve in classrooms where the language of instruction is English.
STUDENT INFORMATION (CONTINUED)
If your child’s country of birth is not the US:
16. When did the student first begin school in the US? _______________________________________________________
17. Did your child attend school before coming to the US?
Yes No
If yes, how many years of school (formal education) did your child complete? _______________________________
18. Can your child read and/or write in their native language?
Yes No
19. Student email address ___________________________________________________________________________________
20. Home Address _____________________________________________________________________ Apt. # ______________
21. City ______________________________________ 22. State ___________________________ 23. Zip _________________
24. Mailing Address (If Different From Home) _____________________________________________ Apt. # ______________
25. City ______________________________________ 26. State ___________________________ 27. Zip _________________
28. Family Home Phone No. _________________________________________________________________________________
29. Student Cell Phone No. __________________________________________________________________________________
3 Revision Date: May 18, 2020
Student Name ____________________________________________
Student ID #___________________________________________________
School ______________________________________________
Grade ________ Homeroom __________________________
Official use only
RACE/ETHNICITY INFORMATION
30. Federal and state regulations require PPS to gather this information for statistical reports.
(Both A and B are required.)
A. Is your child of Hispanic or Latino origin?
Yes No
B. What races do you consider your child? Mark the one or more races that apply.
Asian
Black
Native American or Alaska Native
Native Hawaiian or Other Pacific Islander
White
If you mark “Yes” for A. your student will be reported as Hispanic.
If you mark “No” for A. and select two or more answers to B. your student will be reported as Multi-Racial.
31. Please provide the following additional information to assist PPS in better representing and responding to
our students’ racial/ethnic identities:
What races/ethnicities do you consider your child? Please mark all that apply.
AFRICAN AMERICAN
AFRICAN:
Burundian Eritrean Ethiopian Somali Other African: ___________________________
OTHER BLACK:
Caribbean Island(s): _________________________ Other Black: ___________________________
AMERICAN INDIAN/ALASKA NATIVE:
Alaska Native Burns Paiute Tribe Confederated Tribes of the
Coos, Lower Umpqua and Siuslaw Indians
Confederated Tribes of the Grand Ronde Community of Oregon
Confederated Tribes of Siletz Indians Confederated Tribes of the Umatilla Indian Reservation
Klamath Tribes Confederated Tribes of Warm Springs Coquille Indian Tribe Cow Creek Band of
Umpqua Tribe of Indians
Other American Indian Tribe/Nation: ___________________________________________________________________
Native/Indigenous to Canada (Please describe): ________________________________________________________
ASIAN:
Asian Indian Burmese Cambodian Chinese Filipino Hmong Japanese
Karen Korean Laotian Mien Nepali Thai Tibetan Vietnamese
Other Asian: _________________________________________________________________________________________
HISPANIC/LATINO:
Caribbean Island(s): _______________________________________________________________
Central American Country(s): __________________________________________________________________________
Indigenous Mexican, Central American or South American Mexican
South American Country(s): ________________________ Other Hispanic/Latino: ___________________________
MIDDLE EASTERN/NORTH AFRICAN (Please describe): ________________________________________________
PACIFIC ISLANDER:
Chuukese Guamanian or Chamorro Micronesian Native Hawaiian
Samoan Tongan Other Pacific Islander: _________________________________________________________
WHITE:
Romanian Russian Ukrainian European Country(s): ___________________________________
Other White: _________________________________________________________________________________________
Optional: If you would like to share in your own words how you describe your child’s race, origin, ethnicity,
ancestry and/or Tribal affiliations, please use this space:
________________________________________________________________________________________________________
Revision
Date: May 18, 2020
4
Student Name ____________________________________________
Student ID #___________________________________________________
School ______________________________________________
Grade ________ Homeroom __________________________
Official use only
PREVIOUS SCHOOL INFORMATION
32. School (most recent first) 33. City and State 34. Years Attended (ex.: 2014–15)
1. ________________________________________________________________________________________________________
2. ________________________________________________________________________________________________________
3. ________________________________________________________________________________________________________
4. ________________________________________________________________________________________________________
KINDERGARTEN STUDENTS ONLY
35. In the year before Kindergarten, did your child usually spend 5 hours or more per week in a preschool or
preschool classroom (such as in a school, Head Start, or childcare center)?
Yes No
36. Name of preschool ______________________________________________________________________________________
FAMILY INFORMATION
Contact phone numbers, address and email addresses will be used to distribute important school and district
information. Online access to student records will be provided to each Parent/Responsible Adult listed below.
37. PARENT/RESPONSIBLE ADULT #1:
Lives with student
Yes No (If no, provide full address #42; Check for mailings)
38.
Mother Father Guardian Other ___________________________________________________________
39. Legal Last Name __________________________________ 40. Legal First Name __________________________________
41. Email Address __________________________________________________________________________________________
42. Address (if different from student) ______________________________________________________ Apt. # ____________
43. City ______________________________________ 44. State ____________________________ 45. Zip _________________
46. Mailing Address (if different from home address) ________________________________________ Apt. # _____________
47. City ______________________________________ 48. State ____________________________ 49. Zip _________________
50. Primary Phone No. (Required) ________________________________ Type:
Home Cell Work
The primary phone number will be used for attendance and emergency notifications.
51. Secondary Phone No. (Required) ________________________________ Type:
Home Cell Work
52. Permission to pick up?
Yes No
53. Interested in volunteering?
Yes No
54. Live/work on federal property?
Yes No
55. Member of the Armed Forces on active duty or full-time National Guard?
Yes No
Revision
Date: May 18,
2020
5
Student Name ____________________________________________
Student ID #___________________________________________________
School ______________________________________________
Grade ________ Homeroom __________________________
Official use only
FAMILY INFORMATION (CONTINUED)
Your family has the right to receive information in your home language.
56. Would your family like to have an interpreter for school meetings?
Yes No
Which language? _______________________________________________________________________________________
57. In which language do you want translated printed materials and phone calls?
English Spanish Vietnamese Chinese Russian Somali
58. PARENT/RESPONSIBLE ADULT #2:
Lives with student
Yes No (If no, provide full address #63; Check for mailings)
59.
Mother Father Guardian Other ___________________________________________________________
60. Legal Last Name __________________________________ 61. Legal First Name __________________________________
62. Email Address __________________________________________________________________________________________
63. Address (if different from student) ______________________________________________________ Apt. # ____________
64. City ______________________________________ 65. State ____________________________ 66. Zip _________________
67. Mailing Address (if different from home address) ________________________________________ Apt. # _____________
68. City ______________________________________ 69. State ____________________________ 70. Zip _________________
71. Primary Phone No. (Required) ________________________________ Type:
Home Cell Work
The primary phone number will be used for attendance and emergency notifications.
72. Secondary Phone No. (Required) ________________________________ Type:
Home Cell Work
73. Permission to pick up?
Yes No
74. Interested in volunteering?
Yes No
75. Live/work on federal property?
Yes No
76. Member of the Armed Forces on active duty or full-time National Guard?
Yes No
Your family has the right to receive information in your home language.
77. Would your family like to have an interpreter for school meetings?
Yes No
Which language? _______________________________________________________________________________________
78. In which language do you want translated printed materials and phone calls?
English Spanish Vietnamese Chinese Russian Somali
Revision
Date: May 18,
2020
6
Student Name ____________________________________________
Student ID #___________________________________________________
School ______________________________________________
Grade ________ Homeroom __________________________
Official use only
EMERGENCY CONTACTS
In an emergency, the parent/guardian listed in #37 will be called first, the Parent/guardian listed in #58 will be
called second. By listing a name or names in this section as an emergency contact, you are authorizing
another person or people to pick up your student at school if you cannot be reached.
79. Relationship To Student __________________________ 80. First & Last Name __________________________________
81. Primary Phone No. ________________________________ 82. Other Phone No. __________________________________
83. Relationship To Student __________________________ 84. First & Last Name __________________________________
85. Primary Phone No. ________________________________ 86. Other Phone No. __________________________________
87. Relationship To Student __________________________ 88. First & Last Name _________________________________
89. Primary Phone No. ________________________________ 90. Other Phone No. __________________________________
Please also list an emergency contact who lives at least 100 miles away, for use in a natural disaster when local
phone lines are not available.
91. First & Last Name _________________________________ 92. Primary Phone No. _______________________________
Choose only ONE: If there is an emergency school closure which requires that students are released early, which one
of these plans should your student follow? Your student will…
93.
Leave school and go to home, daycare provider or neighbor as usual
94.
Be picked up by parent or other authorized contact
95.
Go to the home of a designated friend or neighbor
SIBLINGS
Please list student’s sibling(s) currently attending a Portland Public Schools school.
96. Sibling Last Name _________________________________ 97. Sibling First Name _________________________________
98. Relationship to student __________________________ 99. School ______________________ 100. Grade ___________
101. Sibling Last Name ________________________________ 102. Sibling First Name _______________________________
103. Relationship to student _________________________ 104. School _____________________ 105. Grade ___________
106. Sibling Last Name ________________________________ 107. Sibling First Name _______________________________
108. Relationship to student _________________________ 109. School _____________________ 110. Grade __________
Revision
Date: May 18,
2020
7
Student Name ____________________________________________
Student ID #___________________________________________________
School ______________________________________________
Grade ________ Homeroom __________________________
Official use only
STUDENT MEDICAL INFORMATION
School staff need to know if your student has a medical condition for which they may require assistance during
the school day. Remember to advise the school of any changes in information.
111. Doctor’s Name (optional) ____________________________________ 112. Phone No. (optional) __________________
113. Preferred Hospital _____________________________________________________________________________________
County-operated Emergency Medical Services (EMS) makes the final decision for site of best available care whe
n
se
rious illness, accident or other emergency event directs need for transporting to a hospital. If possible, the
school will advise EMS of your hospital preference.
114. Insurance Carrier (optional) _____________________________________________________________________________
c Health Care Reform creates access to medical insurance for everyone at no cost or tax credits to help pay for
health care coverage. If you would like help accessing health coverage, please check the box so we can
contact you.
115. Dentist’s Name (optional) ____________________________________ 116. Phone No. (optional) __________________
117. Please check any current medical conditions:
Serious Allergies ____________________________________________________________________________________
Life Threatening?
Yes No
Asthma
Heart Disease
Seizure Disorder
Diabetes: Type I Type II
118. Other special health needs at school _____________________________________________________________________
119. Medications to be taken at school (please list and also complete the Authorization for Medication form)
______________________________________________________________________________________________________
PROGRAM INFORMATION
120. Does your student have a current Individualized Education Plan (IEP)? Yes No
121. Does your student have a current Section 504 Plan?
Yes No
122. Is your student in a Talented and Gifted (TAG) program?
Yes No
123. Is your student in or has your student been in an English as a Second Language program?
Yes No
124. Is your student in or has your student been in a Dual Language Immersion program?
Yes No
125. Is your student pregnant and/or parenting?
Yes No
Revision
Date: May 18,
2020
8
Student Name ____________________________________________
Student ID #___________________________________________________
School ______________________________________________
Grade ________ Homeroom __________________________
Official use only
FEDERAL TITLE PROGRAM QUESTIONS
(NOTE TO SCHOOL STAFF: If a family checks “Yes” for #126 please fax this page to (503) 916-2728; if “Yes” for #127
and #128 please fax this page to (503) 916-3111.)
Title VI-A Program, Indian Education — This information establishes the district’s eligibility for a federal grant under
the Title VI-A of the Every Student Succeeds Act. You will receive more information if you mark “Yes.”
126. Is the student, a parent, or a grandparent, a member of a U.S. federally recognized/State recognized American
Indian Tribe or Alaskan Native?
Yes No
If Yes, Name of the Tribe, Nation or Village: _______________________________________________________________
Oregon Title I-C Migrant Education Program — This program helps children and young adults ages 3-21 who move
frequently (on their own or with their parents) in order to seek or obtain temporary or seasonal work in agriculture,
forestry and/or fishing activities.
127. A person in my family has worked in, or has planned to work in, agriculture, forestry and/or fishing. This can
include work on farms, ranches, canneries, nurseries, trees or fishing.
Yes No
McKinney-Vento Program — This program guarantees that students, no matter their living situation, have access to
public education, including transportation to and from school. A school district representative will be in touch if you
check a box.
128. Please place a check in the appropriate box if it applies:
c You are staying in a motel, car or campsite until you can find affordable housing.
c Student is not living with or being supported by their parent or guardian. Student living on their own or may
be staying temporarily with someone else.
c You are staying temporarily with another family due to loss of your own housing or economic hardship.
c You are living in a shelter, transitional housing program or moving from place to place without permanent
housing.
c Your housing is substandard: for example the utilities are off, there is severe mold, it is extremely
overcrowded or it is a space not meant for human habitation.
Revision
Date: May 18,
2020
9
Student Name ____________________________________________
Student ID #___________________________________________________
School ______________________________________________
Grade ________ Homeroom __________________________
Official use only
PERMISSIONS/AUTHORIZATIONS
For annual notices on Directory Information, Student Records, Military Recruiting and Protection of Student
Rights, please see the District Parent and Student Handbook.
*Under federal law and school policy, the school district may release the following information without prior parental
consent: Student name, participation in officially recognized activities and sports, weight and height of members of
athletic teams, degrees, honors, and awards received, major field of study, dates of attendance and the most recent
school attended. If you do not want this information released, please contact your school to submit a written
request. This form must be completed each year [Non-Release of Student Directory Information Form].
*Student photographs are commonly used in yearbooks, newsletters, websites and other school-related publications.
If you do not want your student’s photograph used or released for these purposes or for news media, please
contact your school to submit a written request [Publicity Denial and Non-Release of information to School
Directory Form].
*Many schools or PTAs publish school directories that include parent/guardian contact information. If you do not
want your name and contact information released for the school directory, please contact your school to submit
a written request [Publicity Denial and Non-Release of information to School Directory Form].
*If you do not want your student to have access to district-provided email or on-line educational tools including
Google Apps for Education (an online collaboration suite used to increase collaboration between students and
teachers while providing access to a rich toolset for learning), please contact your school.
HIGH SCHOOL ONLY
129. I do not want my child’s name, address and phone number released to:
Military Recruiters College Recruiters
The Every Student Succeeds Act requires school districts to provide, upon request, the names, addresses and
phone numbers of high school juniors and seniors to military recruiters, colleges and universities. If you do not
want the school district to provide information about your student to either the military or colleges and
universities, you have the opportunity to “opt out.” In order to do so, you must check one or both of the
categories above.
By signing this form, I agree that all the information is true. If it is determined that the address I have
provided is false, I acknowledge that my student could be removed from the school immediately.
130. Signature of Parent/Responsible Adult (Required) ________________________________ Date ____________________
131. Signature of Parent/Responsible Adult __________________________________________ Date ____________________
Portland Public Schools wishes you and your student a successful academic school year!
Portland Public Schools recognizes the diversity and worth of all individuals and groups and their roles in society. It is the policy of
the Portland Public Schools Board of Education that there will be no discrimination or harassment of individuals or groups on the
grounds of age, color, creed, disability, marital status, national origin, race, religion, sex or sexual orientation in any educational
programs, activities or employment.
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Completed 13 January 2022

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