STUDENT REGISTRATION FORM Less Than Full Time (Non-Public, Private, Part-Time OE, Global

STUDENT REGISTRATION FORM – Less than full time (non-public, private, part-time OE, Global Academy etc.)

STUDENT INFORMATION (Please print all information)

Birth State

______
Birth Country / _____/______/______
Date Entered US / ______
Nickname / ______
Birth City / ______
Birth County / ______
Birth State / ______
Student Cell Phone

Has this student ever attended a MMSD school in the past? ¨ No ¨ Yes If yes, last MMSD school attended ______

Last school attended, if not in MMSD ______Address______Phone ______

Has this student ever been enrolled in a program because of a disability and/or special need? ¨ No ¨ Yes If yes, what program______

REGISTERING PARENT/GUARDIAN INFORMATION (Please print all information)

Non Household - ADULT EMERGENCY CONTACT INFORMATION (Please print all information)

______

Signature Date 8/2011

RACE AND ETHNICITY DATA COLLECTION:

The school district is required by federal law to ask the following two questions concerning race and ethnicity. Please answer both questions.

Is this student Hispanic or Latino? ¨ Yes, Hispanic or Latino ¨ No, neither Hispanic nor Latino

Select one or more of the following categories that apply to this person (you must select at least one):

¨ American Indian or Alaska Native ¨Asian ¨ Black or African American ¨Native Hawaiian or Other Pacific Islander ¨White

COURSE REQUEST:

(WE,I) request the (our,my) above named child, currently attending, ______who resides at the above address be permitted to attend:

______for the ______school year. (This request is only valid for one school year.)

School (if specific program please indicate)

If the foregoing request is granted, (I,we) agree to provide transportation and understand that excessive absences or tardiness, unsatisfactory conduct or falsification of information on this request is cause for revocation of part-time enrollment. We are requesting permission to attend the above site/courses/program for the following reason(s):

______

______

______

Signature Date

______
Principal Approval* Date

______

Director of Enrollment & Registrar * Date

*Approval signature needed for students taking up to two course that are private or home based MMSD area students.