Boise High School

TIMBERLINE HIGH SCHOOL -Student Census Form

First Day of Enrollment: ______Grade Level: ______Birthdate:______

Student’s LEGAL Name:______

First / GivenMiddleSurname/Family Name

Nickname:______ Male  FemalePlace of Birth:______

If born outside the United States, month/date of US Entry: ______

Last School Attended:______City ______State______

Special Services at Previous School

 504  IEP  ELL Other______Home Language: ______

Ethnicity (Optional)Has the student ever attended a Boise District school before?  Am Indian/Alaska Native  Yes  No If Yes, provide School, Grade & Year:

 Asian ______

 Black/Alaska Native

 Pacific IslanderMedical Information:Recent Booster Date: ______

 WhiteAllergies: ______

 HispanicMedication: ______

Custodial Information (if applicable) – Custody: ____Mother ____Father ____Joint

Non Custodial Parent: ____Permission to see ____Pick up

Copy of custody papers on file? ____Yes____No

Student Residency (Identifying students who may qualify to receive additional services)

Where does the student stay at night?

_____In a home you own or rent

_____Temporarily with another family in a house, mobile home, or apartment

_____Other (please specify):______

Primary Household – Please check here if address is outside of our attendance area: ______

* if so, an open enrollment form will need to be completed/approved.

Home Phone: ______Student Cell #: ______

Residence Address:______

NumberStreetApt/Lot

______

CityStateZip

Mailing (If different):______

Number StreetApt/Lot

______

CityStateZip

Parent/Guardian in Primary Household:

Full Name:______

First / GivenMiddle Surname/Family NameRelation to Student

Cell Phone:______Work Phone:______Employer:______

Email Address:______

Full Name:______

First / GivenMiddle Surname/Family NameRelation to Student

Cell Phone:______Work Phone:______Employer:______

Email Address:______

Generally, a student is eligible for bus transportation if their residence is 1.5 miles or more from their school, or within a board-approved safety busing area. If you believe your child is eligible for school bus transportationyou wish to apply, check here 

______

Parent / Guardian SignatureDate

Secondary Household – If the student lives in both households please check here 

Home Phone: ______

Residence Address:______

NumberStreetApt/Lot

______

CityStateZip

Mailing (If different):______

Number StreetApt/Lot

______

CityStateZip

Parent/Guardian in Secondary Household:

Full Name:______

First / GivenMiddle Surname/Family Name Relation to Student

Cell Phone:______Work Phone:______ MAILINGS

Email Address:______ PORTAL ACCESS

Full Name:______

First / GivenMiddle Surname/Family Name Relation to Student

Cell Phone:______Work Phone:______ MAILINGS

Email Address:______ PORTAL ACCESS

EMERGENCY CONTACTS – (Please provide a person(s) (other than the parents) who could be contacted in an emergency).

Emergency Contact: (full name)______Cell Phone: ______

Relation to Student: ______Work Phone: ______

Emergency Contact: (full name):______Cell Phone: ______

Relation to Student: ______Work Phone: ______

Doctor: ______Phone: ______

ALL CHILDREN LIVING IN THE PRIMARY HOUSEHOLD

______