01/25/2012

District-Wide Official Census Report

and Change of Information Form

Parent Name    Relationship to Student      Cell Phone

Employer    Work Phone   E-mail Address

What phone number should the school use to contact you with messages using our automated message service (Connect Ed)

Parent Name    Relationship to Student      Cell Phone

Employer    Work Phone   E-mail Address     Who receives mail? Select one Mother only Father only Both parents  

Street Address:     Mailing Address:      City, Zip Code  

County of  Residency      Home Phone

Student Information

Student First Name      Student Middle Initial      Student Last Name      Date of Birth

Gender Select Female Male      Ethnic Code Select W-Caucasian/White A-Asian B-African American/Black I-American IndianAlaskan P-Hawaiian/Pacific Islander      Hispanic Select No Yes      Current Grade Select Not enrolled PS PK half day PK full day K half day K full day 1 2 3 4 5 6 7 8 9 10 11 12 13 14

 Reason Non-Attendance (RNA)    Select Enrolled 1-Pre-School 2-Graduated from High School 3-Left School - age 16 or older 4-Received GED      If  4-Received GED enter date received

 Foster Child: Yes    No    Migrant Yes     No    Immigrant Yes     No   If yes, date entered the US:

Who does this child live with? Select one Mother Father Both parents other   If other, please list name and relationship.

Student First Name      Student Middle Initial      Student Last Name      Date of Birth

Gender Select Female Male      Ethnic Code Select W-Caucasian/White A-Asian B-African American/Black I-American IndianAlaskan P-Hawaiian/Pacific Islander      Hispanic Select No Yes      Current Grade Select Not enrolled PS PK half day PK full day K half day K full day 1 2 3 4 5 6 7 8 9 10 11 12 13 14

 Reason Non-Attendance (RNA)    Select Enrolled 1-Pre-School 2-Graduated from High School 3-Left School - age 16 or older 4-Received GED      If  4-Received GED enter date received

 Foster Child: Yes    No    Migrant Yes     No    Immigrant Yes     No   If yes, date entered the US:

Who does this child live with? Select one Mother Father Both parents other   If other, please list name and relationship.

Student First Name      Student Middle Initial      Student Last Name      Date of Birth

Gender Select Female Male      Ethnic Code Select W-Caucasian/White A-Asian B-African American/Black I-American IndianAlaskan P-Hawaiian/Pacific Islander      Hispanic Select No Yes      Current Grade Select Not enrolled PS PK half day PK full day K half day K full day 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Reason Non-Attendance (RNA)    Select Enrolled 1-Pre-School 2-Graduated from High School 3-Left School - age 16 or older 4-Received GED      If  4-Received GED enter date received

 Foster Child: Yes    No    Migrant Yes     No    Immigrant Yes     No   If yes, date entered the US:

Who does this child live with? Select one Mother Father Both parents other   If other, please list name and relationship.