STUDENT ENROLLMENT SUPPLEMENTAL INFORMATION

STUDENT ENROLLMENT SUPPLEMENTAL INFORMATION Fontana Unified School District Student Name: ________________________________________________________________ Grade: ___________ DOB: ______________________ Address: __________________________________________________________ City: ____________________________ Zip: ___________________ School: ____________________________________________ Student ID#: _______________________ Phone #: ____________________________

1. Is your child/student enrolled or has your child/student ever been enrolled in a special program? Yes (Check program below) No  Special Education

 504 Plan

 Gifted and Talented Ed  English Learner Program

If your child/student participated but is no longer in the program: Date exited the program: _________________________ Does your child/student have an IEP (Individualized Educational Program)?  Yes  No

2. Has your child/student ever been retained Yes  No OR expelled?  Yes  No If yes, Grade _________ School ____________________________________ District ____________________________________ 3. Where is your child/family currently living? This information will be used to determine if your child qualifies for additional assistance under the “McKinney-Vento Act”. (Check only one box)  with more than one family in a house or   in a motel or hotel,  in a foster care placement apartment due to economic hardship   in a car, park, or campsite or in a group home placement  temporary with friends or family  in a shelter or transitional housing program  Other  in a permanent house or apartment 4. Who is the student living with?  One (1) parent/Guardian

 Two (2) parents

 1 parent and another adult

 Relative, friend, or another adult not the parent or legal guardian

 Alone with no adults

5. Parent Education – Check the response that describes the education level of the most educated parent.  Graduate Degree or Higher (10)  Some College or Associate’s Degree (12)  Not a High School Graduate (14)  College Graduate (11)  High School Graduate (13)  Declined to State/Unknown (15) The U.S. Department of Education requires all states to collect information on the race and ethnicity of public school students. Please assist us in meeting this state and federal requirement by answering the two questions below. 6. What is your child/student’s ethnicity? (Please check one)  Hispanic or Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)

 Not Hispanic or Latino

7. What is your child/student’s race? (Please check up to five racial categories) The above question is about ethnicity, not race. No matter what you selected above, please continue to answer the following by marking one or more boxes to indicate what you consider your race to be.

 American Indian or Alaskan Native (100) (Persons having

origins in any of the original people of North, Central or South America.)

       

Chinese (201) Japanese (202) Korean (203) Vietnamese (204) Asian Indian (205) Laotian - Asian (206) Cambodian (207) Hmong (208)

        

Other Asian (299) Hawaiian (301) Guamanian (302) Samoan (303) Tahitian (304) Other Pacific Islander (399) Filipino/Filipino American (400) African American or Black (600) White (700) (Persons having origins in any of the original peoples of Europe, North Africa, or the Middle East)

Father’s e-mail: ____________________________________________ Mother’s e-mail: ____________________________________________

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct: ___________________________________________________ Parent/Guardian Signature FOR OFFICE USE ONLY Does student qualify under McKinney-Vento Act? No REV 10/18/17

 Yes:  Foster  Homeless (If Yes original to CWA)

____________________ Date Clerk’s Initials: ______________