ENROLLMENT ASSESSMENT FORM

Enrolling Parent/Guardian/Caregiver

Address

City

State

ZIP

Contact Number

Relationship to Student

Legal Guardian

Address

City

State

Zip

Contact Number

I am seeking to enroll the above named student for the following reason(s): (Check ALL that apply)

Student's parent/legal guardian is incarcerated/in jail

Student's parent/legal guardian is in military on deployment

Student was placed with me by an agency (DHR, DYS, etc)

I have petitioned the court for legal custody

I am a student who is NOT living with a legal parent/guardian

I am living in a temporary housing situation

Other
Other Description

Please explain the current situation (living, custody, etc.):

First Name

Last Name

Race

Gender

DOB

Student Grade Level

Last School Attended

Social Security # or Student #

Zone Location

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Add Another Student #2

Student First Name 2

Student Last Name 2

Student Race 2

Student Gender 2

Student Date Of Birth 2

Student Grade Level 2

Student Last School Attended 2

Social Security # or Student #

Student Zone Location Name 2

Add Another Student #3

Student First Name 3

Student Last Name 3

Student Race 3

Student Gender 3

Student Date Of Birth 3

Student Grade Level 3

Student Last School Attended 3

Social Security # or Student #

Student Zone Location 3

I am seeking to enroll the above named student for the
following reason(s): (Check ALL that apply)

I hereby attest that the information above is true and correct and
I understand that if I falsely enroll the student named above
in a school not in his/her proper attendance zone, the student
may be denied any credit for school work completed while
improperly attending the out-of-district school.

Submitted Date

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