Fillable Com1101 - 2020-2021 Student Registration Form

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Com1101 - 2020-2021 Student Registration Form

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  • 74 check-boxes
  • 80 other fields

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RegistrationForm
School: Grade: SchoolYear:
COM1101 TucsonUnifiedSchool District Revised:01/16/2020
1010E10
th
St.,Tucson,AZ85719|Phone(520)225‐6400
http://www.tusd1.org
1. StudentInformation(PleasePRINTstudentnameex actlyasitappearsonthebirthcertificate )
LegalLastName: LegalFirst Name: FullMi ddl eName:
Gender:
☐Male☐Female
Age:
2. Language 3. DateofBirth 4. CountryofBirth
Primarylanguageusedinthehomeregardlessof
ofthelanguagespokenbythestudent?☐English☐Spanish☐Other______________
Languagemostoftenspokenbythestudent?☐English☐Spanish☐Other______________
Languagethatthestudentfirstacquired? ☐English☐Spanish☐Other______________
MM DD YYYY
☐ UnitedStates
☐Other_____________________
USOnly‐Stateof Birth:
5. RaceandEthnicity(Checkallthatapply) 6. Student’sPRIMARYracial/ethnicidentity(chooseonlyone)
Isthisstude nt
Hispanic/Latino?
☐Yes☐No
☐AmericanIndi an/Alaska Native ☐Asian
☐Bl ack/AfricanAmerica n ☐White
☐Na tiv eHawaiian/P aci fi cIslander
☐Asian ☐ Multiracial
☐White
☐AmericanIndian/AlaskaNative
☐Black/AfricanAmerican
☐NativeHawaiian/Pacific
Islander
☐Hispanic/Latino
7. HomeAddress
ResidentialAddress: City: State: Zip: MailingAddress(ifdifferent): City: State: Zip:
8. Parents/Guardians‐MustbeLegalGuardians–EmergencyContactslistedbelow
Parent/Guardian
StudentLivesWith
Relationship:☐Mother☐Father☐LegalGuardian Interpreterneeded?☐Yes☐NoIfyes,whi ch language?
LastName: FirstName: HomePhone: CellPhone: WorkPhone:
Military:☐Active☐ReserveStart Date: EndDate:
Email: Employer:
Other
Parent/Guardian
☐Al so LivesWithRelationship:☐Mother☐Father☐LegalGuardianInterpreterneeded?☐Yes☐NoIfyes,whichlanguage?
LastName:FirstName:HomePhone:CellPhone:WorkPhone:
Military:☐Active☐ReserveStart Date: EndDate:
Address:City:State: Zip: Email:Employer:
9. Siblings
Name(lastname,firstname) DateofBirthSchool(ifattending) Grade
__________________________________________________ _____________________________________________________________
__________________________________________________ _____________________________________________________________
__________________________________________________ _____________________________________________________________
10. OtherInformation(checkallthatapply)
☐Foster/DCS ☐RefugeeStatus☐Migrant(Agricultural orForestryIndustryDependent)☐TeenParent ☐ChronicIllness
11. EmergencyContacts‐Personswhowillcarefor/pickupstudentifparentcannotbereached.
(mustbe over18andshowphotoID)
Relationship:☐Ste p pa re n t☐Grandparent☐Friend☐Ot h e r___________________________________
Name: HomePhone: WorkPhone: CellPhone:
☐Interpreterneeded?
Language
Relationship:☐Ste p pa re n t☐Grandparent☐Friend☐Ot h e r___________________________________
Name: HomePhone: WorkPhone: CellPhone:
☐Interpreterneeded?
Language
12. EnrollmentHistory
LastSchoolAttended:_______________________________City:____________________State:______
Type:☐TUSD☐Non‐TUSDPublic/Charter☐Private☐Other__________
HasthisstudenteverattendedaTUSDschool?☐Yes☐No
Ifyes,whichschool?_________________________________
13. SpecialClasses,AccommodationsorServices(checkallthat applypastorpresent)
☐Engli s h Language Development☐GATE/Gifted/AcceleratedProgram☐504Plan‐Providecopy☐Special Education☐CurrentIEP‐Providecopy
☐Resource ☐Self‐Contained ☐SpeechTherapy ☐Occupational/PhysicalTherapy ☐Oth e r
14. Transportation
Studentsmustmeeteligibilityguidelin esas listedinBoardPolicyEEA(pleaseseethe TUSDwe bs ite ) .
Ifeligible,willthisstudentridethebus? ☐Yes☐NoIfye s,studentwillride:☐ToandFromSchool☐Toschoolonly☐Fromschoolonly
OfficeUse
Only
PermID#_______________SAIS/EdFiID______________NeighborhoodSchoolVerified:☐Yes☐NoDateEnrolled:____________EntryCode:_______
SynergyEntryDate:______________Enteredby:__________BirthdateVerifiedby:__________☐BirthCert☐BaptismCert☐Other___________
☐ Cohortverifiedby:________SpecialClasses&Accommodations (Box13)notifiedby:504___________GATE___________ELL___________ExEd___________
☐ PictureID☐ProofofResidenc y☐Immunizations☐HealthCard☐PHLOTE☐McKinney‐Vento☐CUMFileReviewed
Parent/GuardianSignature____________________________________________________________Date___________________________
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Com1101 - 2020-2021 Student Registration Form

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Completed 18 July 2020

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