1. No category

(FOR OFFICE USE ONLY)
(FOR OFFICE USE ONLY)
Birth Certificate
Student ID# _________________
__________
Proof of Residence __________
Immunizations
__________
Social Sec. Card
__________
Enrollment Form
Grade
Campus:
STUDENT INFORMATION
__________________
Best Contact Number: ________________________
Legal Name of Student ____________________________________________________________________________________
First
Middle
Social Security # ____________________ Gender
M/F
Last
Date of Birth __________ Home Phone __________________
Street Address _______________________________________________________________________ Apt #: ________
City _______________________________ Zip Code _________________
Place of Birth ________________________
(City, State, Country)
PARENT/GUARDIAN INFORMATION
Household 1
Student Lives with: ______________________________
Household 2 (optional)
Primary address – All mailings will be sent to this address
Complete if different than address for parent/guardian 1
Parent 1 and 2 _____________________________________
Parent 3 and 4 ____________________________________
Relationship to Child ________________________________
Relationship to Child ______________________________
Address __________________________________________
Address _________________________________________
City ___________________ State _______ Zip __________
City ___________________ State _______ Zip __________
Home Phone ______________________________________
Home Phone _____________________________________
Parent 1 Email Address ______________________________
Parent 3 Email Address ____________________________
Parent1 Work Phone ____________________ Ext. ________ Parent 3 Work Phone ___________________ Ext. _______
Parent 1 Cell Phone __________________
Parent 3 Cell Phone __________________
Parent 2 E-mail Address ______________________________
Parent 4 E-mail Address ___________________________
Parent 2 Work Phone ___________________ Ext. _______
Parent 4 Work Phone ___________________ Ext. _____
Parent 2 Cell Phone ________________
Parent 4 Cell Phone ________________
OTHER ROUND ROCK ISD SCHOOLS ATTENDED
School(s) __________________________________________________________
Dates attended ________-_________
Grade Level(s) _____________
Last school attended prior to entering RRISD ________________________________________________________
EMERGENCY CONTACTS
First Person to Contact, if parent/guardian cannot be reached
Name: ___________________________________ Phone: _______________________
Second Person to Contact, if parent/guardian cannot be reached
Name: ___________________________________ Phone: _______________________
Cell: ______________________
Cell: _______________________
CHECK SPECIAL PROGRAM(S) IN WHICH YOUR CHILD RECEIVES SERVICES
Special Education
504
Dyslexia
Bilingual
ESL
TAG
*A person who knowingly falsifies information on a form required for a student's enrollment in the district shall be liable to the
District for tuition or other costs, as provided in Education Code 25.001(h), if the student is not eligible for enrollment but is
enrolled on the basis of false information or false records is a criminal offense under Penal Code 37.10.
To the best of my knowledge the above information is accurate.
________________________________
Signature of Parent/Guardian
______________________
Parent/Guardian Date of Birth
Date
Enrollment Form
Best Contact Number: ________________________
STUDENT HEALTH INFORMATION
Dear Parent/Guardian, The information requested below is needed to maintain an accurate school health record for your child.
Student has experienced a significant health issue/change in the past year: Yes / No
Please understand that this information may be shared with school personnel who have a need to know.
Student Disease History
Diabetes
Vision Loss/Glasses
Asthma
Attention Deficit
Heart Disease/Disorder
Allergies
High Blood Pressure
Neurological
Kidney Disorder
Arthritis
Curvature of Spine
Migraine
Blood Disorder
Seizure Disorder
Hearing Loss/Aid
Chronic Diagnosis
Allergies (Please be Specific)
Medication __________________________________________________________________________________________
___________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Food _______________________________________________________________________________________________
___________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Other_______________________________________________________________________________________________
_____________________________________________________________________________________________________________
Please explain any health issues your child has developed in the past year requiring hospitalization or continued
medical care. (I.e. diabetes, leukemia, seizures, etc.) ________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
I, hereby grant my authorization and consent to medical care, treatment, procedure, or physician consultations
deemed necessary in order to ensure the health of said child.
I will not hold the school district financially responsible for emergency care or transportation of said child.
_______________________________________________
Signature of Parent or Guardian
____________________
Date
2014-2015 PEIM
Texas Education Agency
Texas Public School Student/Staff Ethnicity and Race Data Questionnaire
The United States Department of Education (USDE) requires all state and local education institutions to
collect data on ethnicity and race for students and staff. This information is used for state and federal
accountability reporting as well as for reporting to the Office of Civil Rights (OCR) and the Equal
Employment Opportunity Commission (EEOC).
School district staff and parents or guardians of students enrolling in school are requested to provide this
information. If you decline to provide this information, please be aware that the USDE requires school
districts to use observer identification as a last resort for collecting the data for federal reporting.
Please answer both parts of the following questions on the student’s or staff member’s ethnicity and race.
United States Federal Register (71 FR 44866)
Part 1. Ethnicity: Is the person Hispanic/Latino? (Choose only one)
Hispanic/Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other
Spanish culture or origin, regardless of race.
Not Hispanic/Latino
Part 2. Race: What is the person’s race? (Choose one or more)
American Indian or Alaska Native - A person having origins in any of the original peoples of North
and South America (including Central America), and who maintains a tribal affiliation or community
attachment.
Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the
Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan,
the Philippine Islands, Thailand, and Vietnam.
Black or African American - A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of
Hawaii, Guam, Samoa, or other Pacific Islands.
White - A person having origins in any of the original peoples of Europe, the Middle East, or North
Africa.
____________________________________________________ ________________________________
(Parent/Guardian)/(Staff) Signature
Student/Staff Name (please print)
________________________________
Student/Staff Identification Number
________________________________
Date
This space reserved for school observer – upon completion and entering data in student software
system, file this form in student’s permanent folder.
Ethnicity – choose only one:
Race – choose one or more:
_____ American Indian or Alaska Native
_____ Hispanic / Latino
_____ Asian
_____ Black or African American
_____ Not Hispanic/Latino
_____ Native Hawaiian or Other Pacific Islander
_____ White
Observer signature:
Campus and Date:
Home Language Survey
Encuesta del Idioma que se Habla en Casa
State and Federal Programs
PLEASE COMPLETE ALL INFORMATION
POR FAVOR COMPLETE TODA LA INFORMACIÓN
Student´s Last Name
First Name
Middle Name
Apellido del Estudiante
Primer Nombre
Segundo Nombre
Campus
Student ID #
Grade
Escuela
No. de Identificación Escolar
Grado
______________________________________________________________________________________________________________
TO BE FILLED IN BY PARENT OR GUARDIAN – Este formulario deberá ser completado por el padre, la madre o el tutor legal.
PART A The Texas Education Code §89.1215 requires schools to determine the language(s) spoken at home. Please answer the
PARTE A following questions:
El Código de Educación de Texas §89.1215 requiere que las escuelas determinen el idioma(s) que se habla en casa. Por favor conteste las
siguientes preguntas:
1
What language is spoken in your home most of the time?
2
What language does your child/student speak most of the time?*
¿Qué idioma se habla en su casa la mayor parte del tiempo?
¿Qué idioma habla su hijo/a o el estudiante la mayor parte del tiempo?*
PART B
Place of Birth (Country of Origin) City ______________________ Country____________________
PARTE B
Lugar de Nacimiento (País de origen) Ciudad
País
What is the date of first entry into ANY school (Grades PK-12) in the United States?
¿Cuál es la fecha en que entró por primera vez (PK-12 Grados) a CUALQUIER escuela en los Estados Unidos?
Grade
Month
Year
Grado
Mes
Año
Number of complete academic years (Grades PK-12) in a U.S. school _____________
Número de años académicos (PK-12 Grados) que completó en una escuela de Estados Unidos.
Has your child resided outside the United States for 2 or more consecutive years?
Yes – Sí
¿Ha vivido su hijo/a fuera de los Estados Unidos por dos o más años consecutivos?
Grade
From: (month/year)
To: (month/year)
Does not Apply
Grado
Desde: (mes/año)
Hasta: (mes/año)
No se aplica
No
If your child resided outside the United States, did he/she miss significant portions of one or more school years?
Si su hijo/a vivió fuera de los Estados Unidos, ¿perdió gran parte de uno o más años escolares?
Grade(s)
From: (month/year)
To: (month/year)
Does not Apply
Grado(s)
Desde: (mes/año)
Hasta: (mes/año)
No se aplica
Signature of Parent or Guardian (Grades PK-8) or Signature of Student (Grades 9-12)*
Date
Firma del padre, madre o tutor legal (Pk-8 Grados) o Firma del Estudiante (9-12 Grados)*
Fecha
English/Spanish
State and Federal Programs Department
February 2014