Enrollment Form

  1. Last Name*
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  2. First Name*
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  3. M.I.
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  4. SSN (Last 4 Numbers Only)*
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  5. Date of Birth
    (mm/dd/yyyy)*
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  6. Age*
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  7. City of Birth
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  8. State of Birth
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  9. Gender*

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  10. This Student Hispanic/Latino

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  11. Race (Select one or more)*




  12. Primary language used in the home
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  13. Language most often spoken by the student?
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  14. Language that the student first acquired?
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  15. Internet Browser*
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  16. Operating System*
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  17. Address*
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  18. City*
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  19. State*
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  20. Zip Code*
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  21. Phone*
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  22. Cell Phone
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  23. Email*
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  24. Returning Student

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  25. Last School Attended*
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  26. Last Year Attended*
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  27. Identified for Special Education?

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  28. - If Yes,, Does Student have a current IEP?

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  29. Category of Placement
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  30. MOTHER CONTACT INFO
  31. First Name
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  32. Last Name
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  33. Cell Phone
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  34. Work Phone
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  35. Home Phone
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  36. Address
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  37. City
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  38. State
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  39. Zip Code
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  40. Mother Contact Rights (check all that apply)



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  41. FATHER CONTACT INFO
  42. First Name
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  43. Last Name
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  44. Cell Phone
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  45. Work Phone
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  46. Home Phone
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  47. Address
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  48. City
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  49. State
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  50. Zip Code
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  51. Father Contact Rights



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  52. GUARDIAN CONTACT INFO
  53. First Name
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  54. Last Name
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  55. Cell Phone
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  56. Work Phone
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  57. Home Phone
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  58. Address
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  59. City
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  60. State
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  61. Zip Code
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  62. Guardian Contact righrts



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  63. EMERGENCY CONTACT INFO
  64. First Name
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  65. Last Name
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  66. Relationship to Student
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  67. Cell Phone
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  68. Work Phone
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  69. Home Phone
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