RICHFIELD PUBLIC SCHOOLS ISD #280 7001 HARRIET AVE SO www.richfield.k12.mn.us RICHFIELD, MN 55423 *STUDENT ENROLLMENT FORM* __________________(612) 798 - 6000____ STUDENT’S LEGAL NAME _________________________________

__________________________

(Last name)

Gender:

□Male □Female

___________________

(First name)

(Middle name)

________ (Enrolling Grade)

Birthdate ______/______/_________ Primary Home Language _________________________ Month

Day

Year

Address _________________________________________________________________________________________________ (Number and street name)

(Apt. no.)

Home Phone (_______) _____________ (Area Code)

(City)

(State)

(Zip)

Month/year family moved in __________ Is the student Homeless?

□Yes □No

(Phone Number)

Previously attended a Richfield School?

□Yes □No

□Yes □No

Military Family?

Actively Deployed? □Yes

□No

Last School Attended: _______________________________________________________________________________________ (Name of school)

Program student was in:

(city)

□ESL □Special Education □Gifted/Talented

Racial Background – Check all that apply □ American Indian (including North, South and Central American; and Caribbean) or Alaskan Native

□ Asian (a person having origins in any of the original people

(a person having origins in any of the original people of Hawaii, Guam, Samoa or other Pacific Islands)

□ White (a person having origins in any of the original

in any of the black racial groups of Africa)

□ Hispanic (a person having origins in Mexico, Puerto Rico, Cuba, Central or South America or other Spanish culture or origin, regardless of race) _

□Pre-School

(zip)

□Other_____________

****FOR OFFICE USE ONLY****

□ Native Hawaiian or Pacific Islander

Student Number

________________

Start Date

________________

School Number

________________

Family Number

________________

Last Locn Code

________________

people of Europe, Middle East or North Africa)

of the Far East, Southeast Asia or the Indian subcontinent)

□ Black or African American (a person having origins

(state)

□Title I □Dual Language Immersion

Birth Country: ______________________ If birth country not USA, 1st day of K-12 education in United States:

______/______/_________ Month

Day

Year

Transportation Code ______________

Parent/Guardian (1) ___________________________________________________________________________________________________________ (Last name)

Gender: M F

(First name)

(Middle initial.)

Date of Birth ___________________ Relationship to student ____________________________ Legal Guardian?

□Yes □No

Address (if different from above)_______________________________________________________ Email _______________________________ Student Resides with you?

□Yes •□No

Cell Phone (____)_____________ Work Phone (____)______________ Employer _______________

Parent/Guardian (2) _____________________________________________________________________________________________________________ (Last name)

Gender: M F

(First name)

(Middle initial)

Date of Birth ___________________ Relationship to student ____________________________ Legal Guardian?

□Yes □No

Address (if different from above)_______________________________________________________ Email_______________________________ Student Resides with you?

□Yes □No

Cell Phone (____)_____________ Work Phone (____)_____________ Employer ________________

Please list other children living at this address other than those above (Please use legal names) Last Name

First

Init.

Sex

Birthdate Mo/Day/Yr

Relationship to the Parent/Guardian listed

School (if applicable)

Grade

M F M F M F Minnesota Statutes and Rules require the school district to keep accurate records and updated personal records for pupils. The information will become a part of the student’s permanent cumulative record and will be available to appropriate staff members of District 280. Certain information, known as “directory information”, such as student’s name, name of school attended, grade level, parent(s) name, address and telephone number is available to the public and military recruiters unless the district receives a written request from a parent to withhold this information. The Richfield Public Schools policy on Protection of Privacy of Pupil Records is available at www.richfield.k12.mn.us.

I CERTIFY THE ABOVE INFORMATION IS CORRECT.

Parent/Guardian Signature __________________________________________________________________________ Date ______________________ 6/2015

ENROLLMENT FORM UPDATED JUNE 2015.pdf

Page 1 of 1. RICHFIELD PUBLIC SCHOOLS ISD #280. 7001 HARRIET AVE SO www.richfield.k12.mn.us. RICHFIELD, MN 55423 *STUDENT ENROLLMENT FORM*. (612) 798 - 6000____. STUDENT'S. LEGAL NAME. ______. (Last name) (First name) (Middle name) (Enrolling Grade). Gender: □Male □Female Birthdate ...

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