Enrollment Form
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1
2ENROLLMENT FORM
USD #384 Blue Valley Schools
Student's FULL Legal Name:
Grade:
(First)
(Middle)
(Last)
Home Address:
Home Phone:
City:
State:
Zip:
Cell Phone:
Gender:
Social Security #:
Mailing Address:
Birthdate:
Do you have Internet access at home? ____Yes ____No
City:
State:
Zip:
Resident School District Number:
Father/Guardian:
Email address:
Home Phone:
Cell Phone:
Employer:
Work Phone:
Mother/Guardian:
Email address:
Home Phone:
Cell Phone:
Employer:
Work Phone:
Please indicate with whom the student lives: __________________________________
Email address:________________________________________________________________
Non-Custodial Information - Enter only if a parent does not live in the child's household.
Name:
Do we need to mail separate gradecards, etc. to the non-custodial parent? NO or YES
Mailing address:
City, State Zip:
Home Phone:
Cell Phone:
Employer:
Work Phone:
Race and Ethnicity: (Note: Both Part A and Part B of the question must be answered.)
Part A:
Is this student Hispanic/Latino? (Choose only one)
No, not Hispanic/Latino
Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other
Spanish culture or origin, regardless of race.)
The above part of the question is about ethnicity, not race. No matter what you selected above, please continue to answer the following
by marking what you consider your student's race to be. (Choose one or more)
Part B:
What is the student's race?
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 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.)
What is the language most often spoken/used at home?
Please continue to the other side of this enrollment form.
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