Denver Public Schools

Denver Public Schools Pre-Enrollment Information FormThis 4 page form is required information if your child is not currently attending a Denver Public School (DPS) and you are requesting a DPS school assignment for school year 2010-2011.The following information and documentation must be provided when submitting this Pre-Enrollment form: Proof of Birth: copy of birth certificate, hospital record, non-U.S. passport, or baptismal record. Proof of Residence: copy of lease agreement, utility bill (showing service address), cable bill, Denver County tax notice, warranty deed, bill of sale, settlement statement from closing or a signed contract stating your name, closing date and property address.  Home Language Questionnaire: a separate form given to you from the school secretary.*Other documentation will be requested at the time of Registration* (You will need to complete a registration verification packet for the school your child will be attending.)Please note that due to new Federal requirements for reporting race/ethnicity the questions regarding race/ethnicity have changed.*Early Childhood Education (ECE) or Kindergarten children new to Denver Public Schools do not need to fill out this form. There are separate applications for ECE/K – please ask your school secretary for an application.*Denver Public Schools Pre-Enrollment Information Form 2010 Denver Public SchoolsPre-Enrollment Information Form Page 1 of 4Student Census/Enrollment Information Please printStudent’s Full Legal Name: ______Last First MiddleGrade: ______Gender: M  F  Birth date: ______State/Country of Birth: ______Month Day YearPlease provide verification of birth date to the school – birth certificate, baptismal record, hospital record showing birth, or copy of non-US passportRace/Ethnicity 1 What is your child’s ethnic background: Is child Hispanic or Latino? ❏ Yes ❏ No You must answer question 1 and question 2. Question 1 is about ethnicity, not race. No matter what you selected in question 1, please continue to answer the following question by selecting one or more races.❏ American Indian or Alaskan Native ❏ Native Hawaiian or other Pacific Islander Which of the following groups describes your child's 2 ❏ Asian ❏ Caucasian/White race? (Select all that apply) ❏ Black or African American Failure to answer race and ethnicity questions will result in an observer identifying for you. This question below is similar to the ones you answered above. While it may seem repetitive, it is important that you respond to this question.Which of the following describes your child's race or ❏ American Indian or Alaska Native ❏ Black (not Hispanic) 3 ethnicity? (Choose only one) ❏ White (not Hispanic) ❏ Asian or Pacific Islander ❏ HispanicPrevious School Information Has the student attended another DPS School? Yes  No School: ______Grade: ______School Year: ______Last School Attended Outside the Denver Public SchoolsSchool: ______Grade: ______School Year: ______City: ______State: ______List the first time the student was enrolled in any school in the US (including preschool and kindergarten) Month Year Grade (pk-12)List the most recent time the student was enrolled in any school in the US (NOT including preschool and kindergarten) Month Year Grade (1-12)List the most recent time the student was enrolled in a Colorado public school (NOT including preschool and kindergarten) Month Year Grade (1-12) Is your child presently under an expulsion order from any other school district? Yes  No Is your child presently under consideration for expulsion? Yes  No Is your child presently involved in the Juvenile Justice system? Yes  No I attest under penalty of perjury that all the information provided is true to the best of my knowledge.Parent/Guardian Signature: ______Date: ______Denver Public Schools Pre-Enrollment Information Form 2010 Denver Public Schools For Office Use Only: Student ID ______Pre- Enrollment Information School ______Page 2 of 4Student Name: ______ELA Information Please complete the Home Language Questionnaire included in this packet. If one IS NOT included, please contact the school secretary.Special Services Information Is your child receiving special education services? Yes  No Does your child have a current 504 plan? Yes  No  if yes, please indicate if related to: Academics Health Is your child in any Gifted/Talented programs? Yes  No  if yes, please list______Does your child have any medical alerts? Yes  No  if yes, please explain on page 5.Household Information Please printPlease provide verification of address to the school i.e. –current utility bill, cable bill, current rental agreement, warranty deed, bill of sale, settlement statement from closing, current Denver County tax notice, or signed contract stating your name, closing date and property address. If address is not verifiable additional documentation may be requested. Contact Information to be used for Automated MessengerHousehold Telephone: ______High Priority Attendance Behavior General  Email Address:______High Priority Attendance Behavior General Residence Address: City: State: Zip: Mailing Address: City: State: Zip: Student Lives With: Please check one boxBoth Parents  Mother Only  Father Only  Mother/Stepfather  Father/Stepmother Foster Parents  Relatives  Other  Note: When a student does not reside with both parents, additional information must be on file so that the school can determine who is responsible for the student. If there are applicable legal documents, such as custody papers, a copy should be provided to the school. If the arrangement is less formal another registration packet will need to be submitted. I attest under penalty of perjury that all the information provided is true to the best of my knowledge.Parent/Guardian Signature: ______Date: ______Denver Public Schools Pre-Enrollment Information Form 2010 Denver Public SchoolsFor Office Use Only: Pre-Enrollment Information Form Student ID ______Student Emergency Information School ______Page 3 of 4Student Name: ______Parent/Guardian Contact InformationEmergency Contact # 1  2  3  4  (check only one) Gender: M  F Legal Guardian Name: ______Relationship to Student: ______Yes  No Residence Address: ______Contact information to be used for Automated Messenger Check the Boxes that ApplyOther Telephone: Ext. High Priority Attendance Behavior General Work Telephone: High Priority Attendance Behavior General Cell Telephone: High Priority Attendance Behavior General Email: High Priority Attendance Behavior General Notes: ______Parent/Guardian Contact InformationEmergency Contact # 1  2  3  4  (check only one) Gender: M  F Legal Guardian Name: ______Relationship to Student: ______Yes  No Residence Address: ______Phone Numbers to be used for Automated Messenger Check the Boxes that ApplyOther Telephone: Ext. High Priority Attendance Behavior General Work Telephone: High Priority Attendance Behavior General Cell Telephone: High Priority Attendance Behavior General Email: High Priority Attendance Behavior General Notes: ______Denver Public Schools Students Living in the Household Last Name First Name Middle Name Gender Parent/Guardian Relation to Student DPS School Attending Parent/Guardian #1 Parent/Guardian #2I attest under penalty of perjury that all the information provided is true to the best of my knowledge.Denver Public Schools Pre-Enrollment Information Form 2010 Parent/Guardian Signature: ______Date: ______Denver Public Schools Pre-Enrollment Information Form 2010 For Office Use Only: Denver Public Schools Student ID ______School ______Pre-Enrollment Information Form Student Emergency Information Page 4 of 4Student Name: ______Other Emergency Contact InformationEmergency Contact # 1  2  3  4  5  6  (check only one)Name: ______Relationship to Student: ______Household Telephone: ______Work Telephone: ______Cell Telephone: ______Notes: ______Emergency Contact # 1  2  3  4  5  6  (check only one)Name: ______Relationship to Student: ______Household Telephone: ______Work Telephone: ______Cell Telephone: ______Notes: ______I attest under penalty of perjury that all the information provided is true to the best of my knowledge.Parent/Guardian Signature: ______Date: ______Denver Public Schools Pre-Enrollment Information Form 2010

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