LEWISVILLE ISD REGISTRATION FORM

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					2010-2011
LEWISVILLE ISD REGISTRATION FORM                                      SCHOOL:______________________ZONE:__________

   Photo ID Required for               OFFICE USE ONLY                                        Local ID: ________________________
     Student Release                   Original Entry Date ______________________   Entry Code ________________       Initialed by___________________
                                                              ( MM/DD/YY)                              (O/R/C)                              Registrar)

                                       Withdrawal Date _____________________ Re-Entry Date _________________ Re-Entry Code ________________




STUDENT NAME: ____________________________________________________________________________________________________ GRADE: ___________
                     LAST                                   FIRST                                         MIDDLE



BIRTH DATE: _____________________ PLACE OF BIRTH: _______________________________________ SOCIAL SECURITY #: ___________________SEX: M ___ F___



_________________________________________________________________________________________________________________                TX   ___________________
STREET ADDRESS                        APT #                                          CITY                                                 ZIP



_________________________________________________________________________________________________________________________________________
MAILING ADDRESS IF DIFFERENT FROM PHYSICAL ADDRESS:



ETHNICITY/RACE to be completed on separate page


  HOUSEHOLD 1            (CUSTODIAL PARENT WITH WHICH STUDENT LIVES)
   PRIMARY CONTACT PHONE:

   PRIMARY CONTACT PARENT:                                                            PARENT NAME:

    RELATIONSHIP TO STUDENT:                                            RELATIONSHIP TO STUDENT:

                    CELL PHONE:                                                            CELL PHONE:

                     EMPLOYER:                                                              EMPLOYER:

                   WORK PHONE:                                                            WORK PHONE:

              EMAIL ADDRESS:                                                         EMAIL ADDRESS:




  HOUSEHOLD 2            (NON-CUSTODIAL PARENT, IF APPLICABLE)                       COPY OF DIVORCE DECREE: YES ___ NO___
  PRIMARY PHONE:

             PARENT NAME:                                                             PARENT NAME:

  RELATIONSHIP TO STUDENT:                                              RELATIONSHIP TO STUDENT:



                                                                         CITY                                                  ZIP
                   ADDRESS

               CELL PHONE:                                                                 CELL PHONE:

                   EMPLOYER:                                                                EMPLOYER:

              WORK PHONE:                                                                 WORK PHONE:

            EMAIL ADDRESS:                                                           EMAIL ADDRESS:




HAS STUDENT IMMIGRATED TO THE US WITHIN THE PAST THREE (3) YEARS? YES _____                                        NO _____

HAS STUDENT ATTENDED ANOTHER TEXAS PUBLIC SCHOOL?                                   YES     ___          NO___     IF YES, WHAT YEAR? ______




_____________________________________________________________________________________________________________________________________
Emergency Contact (Not Parent):                             Relationship                      Primary Phone        (type)       Other Phone     (type)




_________________________________________________________________________________________________                     CONTINUED
PARENT/GUARDIAN SIGNATURE                                                                      DATE
2010-2011
STUDENT NAME: _______________________________________________________________ ID#: _______________________

 LAST SCHOOL ATTENDED:                                            HAS STUDENT BEEN PREVIOUSLY ENROLLED IN LEWISVILLE ISD?

               ADDRESS:                                           YES______ NO______
         CITY, STATE ZIP:                                         IF YES, WHICH SCHOOL / YEAR?


 SPECIAL PROGRAMS (CIRCLE THOSE APPLICABLE):

 SPECIAL EDUCATION          GIFTED/TALENTED    ESL     504    OTHER: _______________________________________



     NAME OF SCHOOL AGE BROTHERS & SISTERS                        LEWISVILLE SCHOOL NAME                      GRADE         AGE




OTHER ADULTS AUTHORIZED BY PARENT/GUARDIAN AS EMERGENCY CONTACTS OR TO PICK UP STUDENT:


 NAME:                                               PHONE:                               RELATIONSHIP:


 NAME:                                               PHONE:                               RELATIONSHIP:




     THE SCHOOL WILL ASK FOR IDENTIFICATION BEFORE RELEASING YOUR CHILD TO ANY PERSON.


CIRCLE ANY GRADE YOUR STUDENT HAS REPEATED OR FAILED:

         K          1       2    3      4      5     6        7        8         9         10        11        12

DID THE STUDENT WITHDRAW FROM HIS/HER LAST ATTENDED SCHOOL BEFORE COMPLETING ANY ASSIGNED
DISCIPLINE CONSEQUENCES? YES __________              NO __________


IF YES, PLEASE EXPLAIN: ____________________________________________________________________________________

_________________________________________________________________________________________________________



I GIVE THE SCHOOL PERMISSION TO SECURE SCHOOL RECORDS AND PROPER MEDICAL ATTENTION FOR MY CHILD IN CASE OF
EMERGENCY. I CONFIRM, UNDER PENALTY OF THE LAW, THAT ALL INFORMATION PROVIDED FOR MY CHILD'S REGISTRATION IS
TRUE AND CORRECT. PARENTS ARE RESPONSIBLE FOR NOTIFYING THE SCHOOL OF ANY ADDRESS, TELEPHONE AND EMAIL
ADDRESS CHANGES.


PARENT/GUARDIAN SIGNATURE ______________________________________DATE________________



A PARENT OR PERSON ENROLLING A CHILD WHO PRESENTS FALSE DOCUMENTS OR FALSE RECORDS, COMMITS AN OFFENSE
UNDER SECTION 37.10 OF THE PENAL CODE AND IS SUBJECT TO LIABILITY FOR TUITION OR COSTS UNDER TEA CODE 25.0001(H).
2010-2011
                                          Texas Education Agency
                     Texas Public School Student 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. 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).

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 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, Lorea, 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.

            ______________________________                                      ______________________________
            Student Name (please print)                                         Parent/Guardian Signature


            ______________________________                                      ______________________________
            Student Identification Number                                       Date
 This space reserved for Local 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: