School
/ * Grade / Student District No.EVERETT PUBLIC SCHOOLS
Date of Entry / Bus No. / Bus Stop / Locker No. / Alert Flag
KINDERGARTEN, PRESCHOOL, AND FIRST GRADE ONLY: / Birth Certificate / Other / Birthdate / * Yr. of Grad.
Teacher Name / Teacher No. / Room No. / Alert Flag
S T U D E N T I N F O R M A T I O N
* Student Legal First Name / * LegalMiddle Name / * LegalLast Name
*Gender / Male / Female / * Grade / * Birth date / Student 's Primary Language
Does this child currently receive any of the following services? / Special Ed Classes/IEP / Speech / Occupational or Physical Therapy / ELL / 504 Plan
Born in USA / Yes / No / City of Birth / State of Birth / Country of Birth.
USA Entry Date / USASchool Entry Date / WA School Entry Date
FEDERAL FUNDING: Under Public Law No. 874, the district can receive federal money for each child if the parent is in the active armed forces, lives or works on federal land.
Please Check One: ACTIVE ARMED FORCES LIVES ON FEDERAL LAND WORKS ON FEDERAL LAND DOES NOT APPLY
S T U D E N T A D D R E S S I N F O R M A T I O N
Apt. No. / Complex/Apartment Name
* Street Address / City / Zip Code
* Home Phone / ( ) / Listed / Unlisted / Other – Homeless/Transitional Housing
* Student has a variance? / Yes / No / If yes, out of District or Area
DIRECTORY RELEASEINFORMATION/INTERNET ACCESS: Refer to and complete, if applicable, the Everett Public Schools’ Directory Information form which includes federal Family Educational Rights & Privacy Act (FERPA) release information. The form isattached to the Student Rights and Responsibilitieshandbook.
High School Students Only
Emergency text messages to high school student’s cell phone: Access to this number will enable the district to send a text message toyour high school student’s cell phone if there is an emergency on campus. Sharing your student’s cell phone number is optional. Note: Your student may receive a short message once this service is started to confirm participation.
StudentCell Phone # / ( )
P A R E N T / G U A R D I A N I N F O R M A T I O N
Student lives with / Both Parents [B] / Mother Only [M] / Agency [A] / Guardian [G]
Joint Custody [J] / Father Only [F] / Self [S] / Other [O]
Mother/Stepfather [Y] / Father/Stepmother [X] / Stepfather/Stepmother [Z]
Preferred Language for Communications Home:
* Parent/Guardian Name (1)
Address (if different) / * Work Phone #1 / ( ) / Ext.
Employer
Work Phone #2 / ( ) / Ext.
Guardian (1) Cell Phone / ( )
e-mail address: / Pager No. / ( )
* Parent/Guardian Name (2)
Address (if different) / * Work Phone #1 / ( ) / Ext.
Employer
Work Phone #2 / ( ) / Ext.
Guardian (2) Cell Phone / ( )
e-mail address: / Pager No. / ( )
M E D I C A L I N F O R M A T I O N
Physician Name / Physician Phone Number / ( )
S T U D E N T T R A V E L I N F O R M A T I O N
Bused from Home / Bused from Daycare / Daycare provided Trans. / Parent / Special Bus / Transit / Walker / Car
D A Y C A R E I N F O R M A T I O N
( )
Daycare Name/Contact / Phone Number
Daycare Address / City / Zip Code
A D D I T I O N A L E M E R G E N C Y C O N T A C T S/R E L E A S E **
In case of emergency, if the parent/guardian cannot be contacted
the student maybe released to the emergency contacts listed below
( )
Emergency Contact #1 / Phone Number Work or Home
( )
Emergency Contact #2 / Phone Number Work or Home
P R E V I O U S S C H O O L I N F O R M A T I O N
LastSchool Attended / Date of Entry / Date of Withdrawal
Street Address / City / State / Zip Code
During the past five (5) years, this student has attended the additional schools:
Month/Year / Name of School / City/State / Principal
S I B L I N G I N F O R M A T I O N
Student 's Name / Grade / School Attending
A T T E N D A N C E / D I S C I P L I N E I N F O R M A T I O N
Has this student been referred under the Washington state BECCA Law guidelines for truancy problems? / Yes / No
Is this student currently on a short-term suspension, long-term suspension, or expulsion from his/her previous school? / Yes / No
If yes, effective what date? / For how long?
I attest to the accuracy of this information. If incorrect information is provided, it is grounds for revocation of admission.
** I understand that you will release my student to anyone I have listed above as a Contacts/Release.
Signature / Date / Relationship to Student
Student Name:______
Ethnicity and Race Reporting Requirements
To meet federal and state requirements please fill out the form below.
Note: If no data is provided, we are required to make a selection for you.
Our default selections will be Not Hispanic/Latino and White.
QUESTION 1. Is your child of Hispanic or Latino origin? (Check all that apply.)
NOT HISPANIC/LATINO / MEXICAN / MEXICAN AMERICAN/ CHICANO
CUBAN / CENTRAL AMERICAN
DOMINICAN / SOUTH AMERICAN
SPANIARD / LATIN AMERICAN
PUERTO RICAN / OTHER HISPANIC/LATINO
QUESTION 2. What race(s) do you consider your child? (Check all that apply.)
AFRICAN AMERICAN/ BLACK / ALASKA NATIVE
CHEHALIS
WHITE / COLVILLE
COWLITZ
ASIAN INDIAN / HOH
CAMBODIAN / JAMESTOWN
CHINESE / KALISPEL
FILIPINO / LOWER ELWHA
HMONG / LUMMI
INDONESIAN / MAKAH
JAPANESE / MUCKLESHOOT
KOREAN / NISQUALLY
LAOTIAN / NOOKSACK
MALAYSIAN / PORT GAMBLE KLALLAM
PAKISTANI / PUYALLUP
SINGAPOREAN / QUILEUTE
TAIWANESE / QUINAULT
THAI / SAMISH
VIETNAMESE / SAUK-SUIATTLE
OTHER ASIAN / SHOALWATER
SKOKOMISH
NATIVE HAWAIIAN / SNOQUALMIE
FIJIAN / SPOKANE
GUAMANIAN or CHAMORRO / SQUAXINISLAND
MARIANA ISLANDER / STILLAGUAMISH
MELANESIAN / SUQUAMISH
MICRONESIAN / SWINOMISH
SAMOAN / TULALIP
TONGAN / YAKAMA
OTHER PACIFIC ISLANDER / OTHER WASHINGTON INDIAN
OTHER AMERICAN INDIAN/ALASKA NATIVE
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