Mt. Lebanon School District 7 Horsman Drive ~ Pittsburgh ~ Pennsylvania ~ 15228 To Provide the Best Education Possible for Each and Every Student

PLEASE PRINT

Enrollment Form 105-A

Student Information: (Name of student as shown on Birth Certificate or Passport) Student Last Name

First Name

Street Address

Nick Name

Middle Name

City, State

/ / Date of Birth (MM/DD/YY)

Gender

Zip

Birth Certificate #/Passport #

Age

Grade Entering

Phone Number

City & State of Birth

Ethnicity: Is the student Hispanic or Latino?

Yes

No

Race: (Please check all that apply) Asian White

Black or African American Native Hawaiian / Other Pacific Islander

American Indian or Alaska Native

Parent/Guardian Information: Father: Last Name

Mother: First Name

Mid Initial

Last Name

Address:

First Name

Maiden

Address:

City

State

Zip

Home Phone

Cell Phone

City

State

Home Phone

Email

Zip

Cell Phone

Email

Place of Employment Work Phone Place of Employment Work Phone If parents reside at different addresses: Check if non custodial parent would like copies of mailings.

Proof of Residency Provided: Address identification (sale/rental agreement, utility bill) must be verified by school office.

Shared or Non-Custodial Parent Information: (Complete only if applicable) Student lives with: Non Custodial Parent

Father

Mother

Step Parent (Name) Foster

(Name)

Legal Custody (Choose one):

Placing Agency (Name)

Joint

Sole: Mother Father

Other

(Name) (Attached is a copy of the Court Order indicating limitations for non-custodial parent) Yes No

School Previously Attended:

Grade:

Previous School Address

City

State

Zip

For Students Who Receive Special Services: Please bring any current special education records with you for enrollment. IEP (My child has a current IEP) GIEP (My child has a current GIEP) 504 Service Agreement (My child has a current 504 Service Agreement) English as a Second Language (ESL) (MM/DD/YY) Date entered US / / (MM/DD/YY) Date entered US school / / (MM/DD/YY) Last year entered US school (K-12 only) / / Grade Other (Please explain)

*Complete for Non-Resident Student: Student resides in: Foster Home Contact Name

Group Home

Address

Host Family City

State

Zip

Contact Phone Number: Name of Placing Agency:

Agency Phone Number:

Parent School District of Residence: Address:

Phone Number:

City:

State:

County:

Kindergarten Families ONLY: Please provide any further information regarding placement: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________

Parent/Guardian Signature

Date

Driver’s License Number

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For Office Use Only Registration Date: Start Date: District Entry Date: School Entry Date: State Entry Date: Grade: Homeroom: Counselor: Verifying Signature:

Copies provided to: Guidance Counselor Special Education Teacher Gifted Support Coordinator ESL Coordinator Other

Revised: 1/2/17