Student Enrollment & Registration Form - Atlanta Public Schools

ATLANTAPUBLICSCHOOLSMaking A DifferenceStudent Enrollment & Registration FormDate:School:•- •Last Name: First Name: Middle Name: Suffix:Grade: Gender: Date of Birth: Social Security #:State Country of US School Entry Dateof Birth: Birth: (if not USA) (if after Kindergarten):Home Phone:Student Cell Phone:Home Address: (Street Address) Apt#: City: State: Zip:Does Student Reside in Federally Does Student have an IEP Is Student in ELL/ESOL Program?Subsidized Housing? q Yes No (Special education)? q Yes q No qYes q NoWas/is student in Does student have a Was/Is student involved in the Has the Family lived in anotherGifted/Challenge program? 504 Plan? Student Support Team? county in the last three (3) years?q Yes q No qYes q No qYes q No qYes q NoIf yes, what is the date your family What language(s) did the student first What language(s) does the studentarrived in Fulton county? learn to speak? speak at home?What language(s) does the student What is your child's race (Choose all that apply)?speak most often? q American Indian or Alaska Native (A person having origins in any of the originalpeoples of North and South America (including Central America), and who maintains a tribalaffiliation or community attachment.)q Asian (A person having origins in any of the original peoples of the Far East, SoutheastIs your child Hispanic/Latino? Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan,q No, Not Hispanic/LatinoKorea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.)q Black or African American (A person having origins in any of the Black racial groups ofYes, Hispanic/Latino (A person of Africa — includes Caribbean Islanders and other of African origin.)Cuban, Mexican, Puerto Rican, South q Native Hawaiian or Other Pacific Islander (A person having origins in any of theAmerican, Central American, or other original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)Spanish Culture or origin, regardless of q White (A person having origins in any of the original peoples of Europe, the Middle East.race.or North Africa.)Has anyone in your immediate family been involved in one of the following occupations, either full or part-time or temporarily during thelast three (3) years? (Check all that apply)q Agriculture; planting / picking tomatoes, squash, peppers, etc. q Processing/Packing agricultural productsq Planting, growing, or cutting trees (pulpwood)q Meatpacking / Poultry /Seafoodq Other:q Dairy, Poultry, or Livestockq Fishing or fish farmsName of current/most recent employer:____________________• ••Pre-School Experience: q Home q Private Day Care q Private Pre -School q Babysitter's Home q Head Start q Pre-K ProgramAttended an Atlanta Public School before? Last School Attended in Atlanta Public Previous School Attended(if not Atlanta Public Schools):DYES q NO Schools?Previous School Address (City/State/Zip Code): Previous School Phone #: Grade Date of Withdrawal:Is student currently suspended or pending expulsion from this school?q Yes q NoReason for Current Suspension/ Pending Expulsion/Involuntarywithdrawal:Has student been expelled from ANY school?q Yes q No Reason:Reason for Expulsion/Suspension/Withdrawal:DF-006 Page 1 of 3Revised 06-10-2010

ATLANTAPUBLICSCHOOLSMaking A DifferenceStudent Enrollment & Registration FormDate:School:PARENT/GUARDIAN INFORMATIONStudent Lives With: E Both Parents E Mother only E Father only DLegal Guardian q Foster Parent q GrandparentE Other:(If other than parent, documentation is required.) A student should generally be withdrawnby the person who enrolls them. The parent/legal guardian who enrolled the student may provide the school with written permission accompanied by acopy of the arenUquardian's photo identification for another person to withdraw a child.- ,:the. litImme of the oldest 'chl U have cu enrolled,WMGkiPArIaChar ii;Namigt• I f . :.',* -, --Household Address: Apt#: City: State: Zip:Parent/Guardian Last Name: First Name: Middle Initial:Home Phone: Work Phone: Cell Phone: Other:Marital Status: Employer: Highest Education Received: Speaks English?q YES q NOParent Email Address: Lives on Federal Property? Works on Federal Property? Migrant Worker?q YES q NO q YES q NOq YES q NOParenUGuardian Last Name: First Name: Middle Initial:Home Phone: Work Phone: Cell Phone: Other:Marital Status: Employer: Highest Education Received: Speaks English?q YES q NOParent Email Address:Lives on Federal Property? Works on Federal Property? Migrant Worker?Name:q YES q NO q YES q NONON-HOUSEHOLDRelationship:PERSONS/EMERGENCY CONTACTSHome Phone:q YESCell Phone:Name: Relationship: Home Phone: Cell Phone:q NOName:Relationship:Home Phone:Cell Phone:Sibling Last Name:Enrolled in APS School:EYES ONOSIBLING INFORMATIONFirst Name:Birth Date:Name of APS School in which currently enrolled:Gender: . Male q FemaleGrade:41M -t V El iSibling Last Name: First Name: Birth Date: Gender: M Male q FemaleEnrolled in APS School:Name of APS School in which currently enrolled:OYES ONOSWIO- IrNOMe: F!*NOme: 17DMIVSe:Enrolled' in APS School:0'Name of APS School in which- - , : -.-_ntty enrolled:Grade:Winder y' ' 6:-AaleQateateDF-006Revised 06-10-2010Page 2 of 3

IAII1kiitg AAT i.AN'i APUBLICCH OLDiffereneeStudent Enrollment & Registration FormDate:School:• -^ •understand that a student admi tted under false information is illegally enrolled and will be dismissed or reassigned from Atlanta PublicSchools upon discove ry. Further, I understand that a person who knowingly and willfully... makes a false, fictitious, or fraudulent statement orrepresentation; or makes or uses any false writing or document, knowing the same to contain any false, fictitious, or fraudulent statement ofentry, in any matter... shall upon conviction thereof, be punished by a fine of not more than $1,000.00 or by imprisonment for not less thanone nor more than five years, or both (O.C.G.A. 16-10- 20). False information may result in the loss of a student's athletic eligibility for onecalendar year. I further understand that it is my responsibility as the Parent/Legal Guardian to immediately inform the school district of anychanges in the information provided. Residenc y Notice : To be enrolled in Atlanta Public Schools, students must reside full-time in the City of Atlantawith their natural parent(s), legal guardian(s), or legal custodian(s). Students and their parent(s)/guardian(s)/custodian(s) must remain full-time City ofAtlanta residents for the entire period of enrollment in Atlanta Public Schools. For the purpose of this policy, a resident is defined as an individual who isa full-time occupant of a dwelling located in the City of Atlanta and who, on any given school day, is likely to be at their stated address when not at workor school. A person who owns property in the City of Atlanta, but does not reside in the City of Atlanta, is not considered a resident for thepurpose of this policy.SWEAR or AFFIRM THAT I AM A FULL-TIME RESIDENT OF THE CITY OF ATLANTA OR I AM ANEMPLOYEE OF ATLANTA PUBLIC SCHOOLS AND AFFIRM THAT THE INFORMATION I HAVE GIVEN INTHIS DOCUMENT IS, TO THE BEST OF MY KNOWLEDGE, TRUE AND CORRECT.Parent/Legal Guardian Signature:Parent/Legal Guardian Signature:Date:Date:PLEASE DO NOT WRITE BELOW THIS LINE - SCHOOL USE ONLYDF-006 Page 3 of 3Revised 06-10-2010