WAKEFIELD PUBLIC SCHOOLS REGISTRATION FORM

School:

Grade:

Homeroom:

Enrollment Date:

*Child’s Name: First

Middle

Street *Date of Birth:

Apt. #

Last

Address: *Gender: Home Phone:

Emergency Phone:

Parent/Guardian Name

Address

Parent/Guardian Occupation

Birthplace

Parent/Guardian Name

Address

Parent/Guardian Occupation

Birthplace

Guardian / Foster Parent’s Name *Home Language: *Ethnic Background (Select One)     

Town *City / Town of Birth:

Address

Cell Phone # Email Cell Phone # Email Phone # *Primary Language of Student:

American Indian or Alaskan Native: A person having origins in any of the original people of North America, and who maintains cultural identification through tribal affiliation or community attachment. Asian or Pacific Islander: A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent or the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands and Samoa. Black: A person having origins in any of the black racial groups of Africa White: A person having origins in any of the original people of Europe, North Africa, or the Middle East. Hispanic: A person of Mexican, Puerto Rican, Cuban, Central or South America or other Spanish culture of origin, regardless of race.

*Low Income Status (Select One)  The student is eligible for free or reduced lunch; or receives Transition Aid to Families benefits; or is eligible for food stamps.  Not Applicable *Perkins Low Income Status (Select One)  The family has an annual income below the federal poverty guidelines; or the family receives Transitional Aid to Families; or the student is a state ward (foster child) or is in an institution for the neglected or delinquent; or the student is eligible for free/reduced price lunch.  Not Applicable *Migrant Status (Select One)  An indication of whether an individual or a parent/guardian accompanying an individual maintains primary employment in one or more agricultural or fishing activities on a seasonal or other temporary basis and establishes a temporary residence for the purpose of such employment.  Not Applicable *Immigrant Status (Select One)  An indication of whether a student is eligible for the Emergency Immigrant Education Program is, the student must not have been born in any State (any of the 50 states, the Commonwealth of Puerto Rico, the district of Columbia, Guam, American Samoa, the Virgin Islands, the Northern Mariana Islands, or the territory of the Pacific Islands) and not having completed 3 full academic years of school in any state. *Country of Origin  Not Applicable Signature *Information required by State

Date