Parent/Guardian Signature ________________________________ Date __________________
2122 DCSD Reg Form 101420
Page 1 of 6
What is/was the student's first language? _______________________________________________________
Does the student speak a language(s) other than English? Y N
Not including language learned in school courses or academic enrichment programs
(i.e., world language classes or clubs)
If yes, specify the language(s). _____________________________________________________________
What language(s) is/are spoken in your home? __________________________________________________
Date of Enrollment: __________________ Start Date: _______________
Student ID #: __________________ Grade: _______ Room: __________
Teacher/Counselor: ______________________ Track/Team: __________
Session: AM PM Permit Code: ________ Bus #: __________
For Office use Only
School:
* * * P L E AS E P R I N T * * *
2021-2022
Legal Name from Birth Certificate
___________________________________________________________ Nickname _________________
Grade _______ Gender M F Date of Birth _____________
Cell ____________________
Residence Address ________________________________________________________________________
City ____________________________ State _____ Zip _________ Email _______________________
American Indian or Alaskan Native - A person having origins in any of the original peoples of North and South America
Black or African American - A person having origins in any of the black racial groups of Africa.
Asian - A person having origins of any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for
Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or
White - A person having origins in any of the original peoples of Europe, the Middle East or North Africa
Has the student attended another Douglas County School District school? Y N
If Yes, School ____________________________________ Grade ______ School Year ___________
Last school attended outside the Douglas County School District:
School _________________________________ City ________________ State _____ Grade _____
Is your child presently under an expulsion order from any other school district? Y N
Is your child presently under consideration for expulsion? Y N
Is your child presently involved in the Juvenile Justice system? Y N
Last First Middle (full)
Is your child currently on an Individual Educational Plan for Special Services? Y N
Has your child received any previous testing, evaluations or services in any of the following areas?
Learning Disabilities Counseling Gifted & Talented READ Plan
Speech/Language Psychological Remedial Reading (Title 1)
Physical Therapy Behavioral Difficulties 504 Services
Occupational Therapy Hearing/Visual Impaired Other
Student
Information
Previous SchoolSpecial Services Race/Ethnicity
Part A. Is this student Hispanic / Latino? (choose only one)
No. NOT Hispanic
Yes. Hispanic/Latino -
A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or
The above part of the question is about ethnicity, not race. No matter what you selected in Part A above, please provide an
Part B. Which of the following groups describe the student's race? (choose one or more)
Notice to Parents and Students - Parents and students should be aware that if they choose not to answer the two-
part question, school districts are required to identify an ethnicity and race on behalf of the student, based on several factors,
including observation, in accordance with U.S. Department of Education and Colorado Department of Education Guidelines.
origin, regardless of race.
(including Central America), and who maintains tribal affiliation or community attachment.
example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Phillippine Islands, Thailand, and Vietnam.
other Pacific Islands.
answer to Part B by marking one or more boxes below to indicate what you consider your child's race to be.
Phone
Use Dropdown to Select School
Do you need an interpreter for school meetings and events? This includes family events, parent-teacher conferences,
formal plan meetings (IEP, 504, ALP, READ, ELLP), registration and enrollment, etc. Y N
Interpreter
Needed?
Douglas County School District
Student Census
Registration Form
ELD
