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TODAY’S DATE

CARROLLTON PUBLIC SCHOOL DISTRICT 3211 Carla Drive/P.O. Box 517, Carrollton, MI 48724 Telephone: 989-754-1475 Fax: 989-754-1470

REGISTRATION FORM STUDENT’S LEGAL NAME Last First Middle

Has student previously attended Carrollton Public Schools? Yes___ No___ Date Left________________

Has student previously enrolled here under a different name? Yes No Previous Name Has student previously enrolled in a Michigan District? Yes_____ No______ Prior District/when?

Sex M____ F____

Expected Start Date Month - Day- Year ___-___-___

Do you consider student to be multi-racial: Yes__ No__ *Please select all that apply* Student’s Ethnic Background: Asian or Pacific Islander___ American Indian or Alaskan Native Origin___ Hispanic___ White – Not of Hispanic Origin___ Black – Not of Hispanic Origin___

STUDENT’S GRADE _____ ___________ Last School Attended: Name City Non-Public: Y__ N__ Home School: Y__ N__ Dates Attended:

STUDENT’S ADDRESS & TELEPHONE NO. (___)__________ Number & Street________________________Apt../Lot________ City State Zip_______ PO Box # City Zip_______ Student Lives With: Both Parents___ Foster Parents___

Student’s Birth Date Student’s Soc. Sec. No. Month – Day – Year _____-_____-_____ ___________________ Birth Place_____________________(City & State)

By Michigan statute, information about social security number, language and ethnic background is considered private data. You are not obligated to provide this data. It will be used for receiving correct state aid payments to our district. Were special education services provided at the last school? Yes____ No____

State

Did student have an IEP? Yes____ No____

Circle Highest Grade Completed Mother’s Education: 1 2 3 4 5 6 7 8 9 10 11 12/ 1 2 3 4 5 6 Father’s Education: 1 2 3 4 5 6 7 8 9 10 11 12/ 1 2 3 4 5 6

Mother___ Father___ Father/Stepmother___ Mother/Stepfather___ Other (Please Specify Relationship)_________________________

Guardians___

Legal Name of CUSTODIAL Parent/Guardian #1 (Adult Student Lives With): Last Birth Date First Sex: Male Female Middle Employer Occupation Work Phone ( )___________ Work Days___ A’noons___ Eves.___ Cell Phone ( )____________E-mail:_________________________ Relationship to Student:____________________________ Marital Status: Single____ Married____ Separated____

Legal Name of NON-CUSTODIAL Parent (Adult Student Does Not Live With): Last Birth Date First Sex: Male Female Address City State Employer Occupation Work Phone ( )____________ Work Days_____ A’noons_____ Eves.______ Cell Phone ( )____________ E-mail: Relationship to Student: Marital Status: Single Married Separated

Legal Name of CUSTODIAL Parent/Guardian #2 (Adult Student LivesFather’s With): Last Birth Date First Sex: Male Female Middle Employer Occupation Work Phone ( )___________ Work Days___ A’noons___ Eves.___ Cell Phone ( )____________ E-mail:________________________ Relationship to Student:____________________________ Marital Status: Single____ Married____ Separated____

Legal Name of NON-CUSTODIAL Parent (Adult Student Does Not Live With): Last Birth Date First Sex: Male Female Address City State Employer Occupation Work Phone ( ) ____________ Work Days_____ A’noons_____ Eves.______ Cell Phone ( ) _____________ E-mail: Relationship to Student: Marital Status: Single____ Married____ Separated____

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