Household Information (One form per Family)
Date:______Head of the Household ______
Last Name First Initial
PRIMARY HOUSEHOLD INFORMATION
Physical Address
NUMBER STREET APT/LOT
CITY STATE ZIP
Mailing Address
(if different) P.O. BOX (OR OTHER MAILING ADDRESS)
CITY STATE ZIP
(Check if Unlisted) Home Phone ______
This is the phone number that will be used for Call Command.
Parent or Guardian 1 (This is the primary parent/guardian for the Household Address listed above.)
LEGAL Name
FIRST MIDDLE LAST
D.O.B. ______Cell Phone ______Work Phone ______
Email Address______ Male Female
______
Employer Name Employer Address (Street/City/State/Zip)
Parent/Guardian Legal Guardian (by court) Stepparent Foster Parent Other (specify)______
Race: White Black American Indian Asian/Islander Hispanic Other ______
Parent or Guardian 2 (This is either the second parent/guardian or a step-parent living in the household address above.)
LEGAL Name
FIRST MIDDLE LAST
D.O.B. ______Cell Phone ______Work Phone ______
Email Address______ Male Female
______
Employer Name Employer Address (Street/City/State/Zip)
Parent/Guardian Legal Guardian (by court) Stepparent Foster Parent Other (specify)______
Race: White Black American Indian Asian/Islander Hispanic Other ______
LIST OTHER ADULTS IN THIS HOUSEHOLD
Name:______Relationship in household:______
Name:______Relationship in household:______
Name:______Relationship in household:______
Secondary Household [This section should be completed if one or both parent/legal guardians live at different address from student(s).]
Physical Address
NUMBER STREET APT/LOT
CITY STATE ZIP
Mailing Address
(if different) P.O. BOX (OR OTHER MAILING ADDRESS)
CITY STATE ZIP
(Check if Unlisted) Home Phone ______
Parent or Guardian 3 (This will generally be a parent who does NOT live in the Primary Household with the students.)
LEGAL Name
FIRST MIDDLE LAST
D.O.B. ______Cell Phone ______Work Phone ______
Email Address______ Male Female
______
Employer Name Employer Address (Street/City/State/Zip)
Parent/Guardian Legal Guardian (by court) Stepparent Foster Parent Other (specify)______
Race: White Black American Indian Asian/Islander Hispanic Other ______
Is this person legally restricted from access to the student(s)? ______(If so, a copy of court order MUST be provided.)
Parent or Guardian 4 (This will generally be the individual living with a parent in a Secondary Household.)
LEGAL Name
FIRST MIDDLE LAST
D.O.B ______Cell Phone ______Work Phone______
Email Address______ Male Female
______
Employer Name Employer Address (Street/City/State/Zip)
Parent/Guardian Legal Guardian (by court) Stepparent Foster Parent Other (specify)______
Race: White Black American Indian Asian/Islander Hispanic Other ______
Is this person legally restricted from access to the student(s)? ______(If so, a copy of court order MUST be provided.)
If parents/guardians wish to set up an Infinite Campus Portal Account to check students' grades, schedules, etc., please check "Infinite Campus Portal Account" box. You will be e-mailed an activation key number with instructions on how to set up your account.
Please List All Children in Primary Household(Even if not enrolled in school)
1st Student’s LEGAL Name:
FIRST MIDDLE LAST
Gender ______Date of Birth ______Grade ______School ______
Social Security # ______Has guardianship for this child changed recently? Yes or No (circle one)
Relationship to Guardian 1: :______Relationship to Guardian 2:______
Relationship to Guardian 3: :______Relationship to Guardian 4:______
Ethnicity: Is this child Hispanic/Latino: Yes or No (circle one)
Race: (check ALL that apply) ___White ___Black or African American ___Native Hawaiian or other Pacific Islander
___Asian ___American Indian or Alaskan Native
2nd Student’s LEGAL Name:
FIRST MIDDLE LAST
Gender ______Date of Birth ______Grade ______School ______
Social Security # ______Has guardianship for this child changed recently? Yes or No (circle one)
Relationship to Guardian 1: :______Relationship to Guardian 2:______
Relationship to Guardian 3: :______Relationship to Guardian 4:______
Ethnicity: Is this child Hispanic/Latino: Yes or No (circle one)
Race: (check ALL that apply) ___White ___Black or African American ___Native Hawaiian or other Pacific Islander
___Asian ___American Indian or Alaskan Native
3rd Student’s LEGAL Name:
FIRST MIDDLE LAST
Gender ______Date of Birth ______Grade ______School ______
Social Security # ______Has guardianship for this child changed recently? Yes or No (circle one)
Relationship to Guardian 1: :______Relationship to Guardian 2:______
Relationship to Guardian 3: :______Relationship to Guardian 4:______
Ethnicity: Is this child Hispanic/Latino: Yes or No (circle one)
Race: (check ALL that apply) ___White ___Black or African American ___Native Hawaiian or other Pacific Islander
___Asian ___American Indian or Alaskan Native
RACE/ETHNIC GROUP DESCRIPTIONS
- White (not Hispanic) – A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
- Black/African American (not Hispanic) – A person having origins in any of the black racial groups of Africa.
- Hispanic/Latino – A person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture of origin regardless of race.
- Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent.
- Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
- American Indian or Alaska Native – A person having origins in any of the original peoples of North & South America and who maintains culture identification thru tribal affiliation or community attachment.
4th Student’s LEGAL Name:
FIRST MIDDLE LAST
Gender ______Date of Birth ______Grade ______School ______
Social Security # ______Has guardianship for this child changed recently? Yes or No (circle one)
Relationship to Guardian 1: :______Relationship to Guardian 2:______
Relationship to Guardian 3: :______Relationship to Guardian 4:______
Ethnicity: Is this child Hispanic/Latino: Yes or No (circle one)
Race: (check ALL that apply) ___White ___Black or African American ___Native Hawaiian or other Pacific Islander
___Asian ___American Indian or Alaskan Native
5th Student’s LEGAL Name:
FIRST MIDDLE LAST
Gender ______Date of Birth ______Grade ______School ______
Social Security # ______Has guardianship for this child changed recently? Yes or No (circle one)
Relationship to Guardian 1: :______Relationship to Guardian 2:______
Relationship to Guardian 3: :______Relationship to Guardian 4:______
Ethnicity: Is this child Hispanic/Latino: Yes or No (circle one)
Race: (check ALL that apply) ___White ___Black or African American ___Native Hawaiian or other Pacific Islander
___Asian ___American Indian or Alaskan Native
6th Student’s LEGAL Name:
FIRST MIDDLE LAST
Gender ______Date of Birth ______Grade ______School ______
Social Security # ______Has guardianship for this child changed recently? Yes or No (circle one)
Relationship to Guardian 1: :______Relationship to Guardian 2:______
Relationship to Guardian 3: :______Relationship to Guardian 4:______
Ethnicity: Is this child Hispanic/Latino: Yes or No (circle one)
Race: (check ALL that apply) ___White ___Black or African American ___Native Hawaiian or other Pacific Islander
___Asian ___American Indian or Alaskan Native
RACE/ETHNIC GROUP DESCRIPTIONS
- White (not Hispanic) – A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
- Black/African American (not Hispanic) – A person having origins in any of the black racial groups of Africa.
- Hispanic/Latino – A person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture of origin regardless of race.
- Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent.
- Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
- American Indian or Alaska Native – A person having origins in any of the original peoples of North & South America and who maintains culture identification thru tribal affiliation or community attachment.
Student Residency Survey
Do your children live with friends or family members in a home in which their parents/guardians don’t live? /
- Yes
- No
Do your children live with more than one family in a house or apartment? /
- Yes
- No
Do your children live in a motel, car, or campsite? /
- Yes
- No
Do your children live in a shelter? /
- Yes
- No
Home Language Survey
Country of Birth ______Language most frequently spoken at home ______
Language your children began to speak when he/she first began to talk ______
Language your child most frequently speaks at home ______
Primary language spoken to your children (Father) ______(Mother)______
First Entry in US school ______
Needs Survey
I currently receive: (please check all that apply)
□ Food Stamps
□ Medical Card
□ K-Chip Insurance
□ Enrolled in Adult/GED Education Classes
□ Parenting Classes / I am in need of the following: (please check all that apply)
□ Food Stamps
□ Medical Card
□ K-Chip Insurance
□ Adult/GED Education Classes
□ Parenting Classes
□ Other ______
______
Name of Person Completing Form (Please Print) Signature of Person Completing Form
For Office Use OnlyDate Form Processed ______
Transportation/Bus Number ______NT ______
Main Bus Connector Bus
Verification of Residence ______Verification of Guardian ______