NACP: 2021-2022 Enrollment Form Integrated

2021-2022 Student Enrollment Form
Family Name*
Select No of Students for Enrollment*

1234
Student Information
Student 1 Information
Student 1 Legal Name*

First NameMiddle NameLast Name
Other Legal Name (If any)
Gender*

MaleFemale
Student’s Date of Birth*

MonthDayYear
Date
Grade-Level for 2021-2022 school year*
WHAT IS YOUR CHILD’S ETHNICITY? ( (Information is used for CALPADS and other school reports)*

Hispanic or Latino (A person of Cuban,Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race)Not Hispanic or Latino
WHAT IS YOUR CHILD’S RACE? (Information is used for CALPADS and other school reports) The above part of the question is about ethnicity, not race. No matter what you selected above, please continue to answer thefollowing by marking one or more boxes to indicate what you consider your race to be.

American Indian or Alaskan Native(100)(Personas cuyo origen es de los pueblos nativos de Norte, Centro o Sudamérica)Chinese (201)Japanese (202)Korean (203)Vietnamese (204)Asian Indian (205)Laotian (206)Cambodian (207)Hmong (208)Other Asian (299)Hawaiian (301)Guamanian (302)Samoan (303)Tahitian (304Other Pacific Islander (399)Filipino/Filipino American (400)African American or Black (600)White (700)
Date first attended school in the U.S.

MonthDayYear
Date
Date first attended school in California

MonthDayYear
Date
Birth Place

CityStateCountry
Home Language Survey (Indicate only one language (most frequently used) per line)
Which language did your child learn when he/she first began to talk?
Which language does your child most frequently speak at home?
Which language do you (the parent or guardians) most frequently use when speaking with your child?
Which languages is most often spoken by adults in the home?
In which language do you wish to receive written communications from the school?*

EnglishSpanish
Residence – where is your child/family currently living? ((Information is use for CALPADS and other school reports): Please check appropriate box:

In a single family permanent residence (house, apartment, condo, mobile home) (200)In a motel/hotel (110)In a shelter or transitional housing program (100)Unsheltered (car/campsite) (130)Other
Parent/Guardianship Information (with whom the student lives) – check all that apply

FatherMotherBothStep-FatherStep-MotherGuardianFoster/Group HomeOther
Is the above (checked) person (s) the student’s LEGAL guardian?

YesNo
Please complete a “Caregiver Affidavit”
If there is a legal custody agreement regarding this student, please check one

Joint CustodySole CustodyGuardian
DUPLICATE MAILING – If divorced/separated & joint custody allows duplicate mailing/information to be given to other parent, Please include their name, address, and phone number
Full Name*

First NameLast Name
Phone Number
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MOST RECENT SCHOOL ATTENDED
School Name
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Grade(s)
Date
Are there psychological or confidential reports available from your child’s former school?

YesNo
What special services has your child received? (please check all boxes that apply)
Special Education

Resource (RSP)Special Day Class (SDC)Speech/Language504
Other

Gifted (GATE)Remedial MathRemedial ReadingCounselingEnglish Language DevelopmentHelp to Improve Attendance/ BehaviorOther
Student 2 Information
Student 2 Name*

First NameMiddle NameLast Name
Gender*

MaleFemale
Student’s Date of Birth*

MonthDayYear
Date
Grade-Level for 2020-2021 school year*
WHAT IS YOUR CHILD’S ETHNICITY? ( (Information is used for CALPADS and other school reports)*

Hispanic or Latino (A person of Cuban,Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race)Not Hispanic or Latino
WHAT IS YOUR CHILD’S RACE? (Information is used for CALPADS and other school reports) The above part of the question is about ethnicity, not race. No matter what you selected above, please continue to answer thefollowing by marking one or more boxes to indicate what you consider your race to be.

American Indian or Alaskan Native(100)(Personas cuyo origen es de los pueblos nativos de Norte, Centro o Sudamérica)Chinese (201)Japanese (202)Korean (203)Vietnamese (204)Asian Indian (205)Laotian (206)Cambodian (207)Hmong (208)Other Asian (299)Hawaiian (301)Guamanian (302)Samoan (303)Tahitian (304Other Pacific Islander (399)Filipino/Filipino American (400)African American or Black (600)White (700)
Date first attended school in the U.S.

MonthDayYear
Date
Date first attended school in California

MonthDayYear
Date
Birth Place

CityStateCountry
Home Language Survey (Indicate only one language (most frequently used) per line)
Which language did your child learn when he/she first began to talk?
Which language does your child most frequently speak at home?
Which language do you (the parent or guardians) most frequently use when speaking with your child?
Which languages is most often spoken by adults in the home?
In which language do you wish to receive written communications from the school?*

EnglishSpanish
Residence – where is your child/family currently living? ((Information is use for CALPADS and other school reports): Please check appropriate box:

In a single family permanent residence (house, apartment, condo, mobile home) (200)In a motel/hotel (110)In a shelter or transitional housing program (100)Unsheltered (car/campsite) (130)Other
Parent/Guardianship Information (with whom the student lives) – check all that apply

FatherMotherBothStep-FatherStep-MotherGuardianFoster/Group HomeOther
Is the above (checked) person (s) the student’s LEGAL guardian?

YesNo
Please complete a “Caregiver Affidavit”
If there is a legal custody agreement regarding this student, please check one

Joint CustodySole CustodyGuardian
DUPLICATE MAILING – If divorced/separated & joint custody allows duplicate mailing/information to be given to other parent, Please include their name, address, and phone number
Full Name*

First NameLast Name
Phone Number
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MOST RECENT SCHOOL ATTENDED
School Name
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Grade(s)
Date
Are there psychological or confidential reports available from your child’s former school?

YesNo
What special services has your child received? (please check all boxes that apply)
Special Education

Resource (RSP)Special Day Class (SDC)Speech/Language504
Other

Gifted (GATE)Remedial MathRemedial ReadingCounselingEnglish Language DevelopmentHelp to Improve Attendance/ BehaviorOther
Student 3 Information
Student 3 Name*

First NameMiddle NameLast Name
Gender*

MaleFemale
Student’s Date of Birth*

MonthDayYear
Date
Grade-Level for 2020-2021 school year*
WHAT IS YOUR CHILD’S ETHNICITY? ( (Information is used for CALPADS and other school reports)*

Hispanic or Latino (A person of Cuban,Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race)Not Hispanic or Latino
WHAT IS YOUR CHILD’S RACE? (Information is used for CALPADS and other school reports) The above part of the question is about ethnicity, not race. No matter what you selected above, please continue to answer thefollowing by marking one or more boxes to indicate what you consider your race to be.

American Indian or Alaskan Native(100)(Personas cuyo origen es de los pueblos nativos de Norte, Centro o Sudamérica)Chinese (201)Japanese (202)Korean (203)Vietnamese (204)Asian Indian (205)Laotian (206)Cambodian (207)Hmong (208)Other Asian (299)Hawaiian (301)Guamanian (302)Samoan (303)Tahitian (304Other Pacific Islander (399)Filipino/Filipino American (400)African American or Black (600)White (700)
Date first attended school in the U.S.

MonthDayYear
Date
Date first attended school in California

MonthDayYear
Date
Birth Place

CityStateCountry
Home Language Survey (Indicate only one language (most frequently used) per line)
Which language did your child learn when he/she first began to talk?
Which language does your child most frequently speak at home?
Which language do you (the parent or guardians) most frequently use when speaking with your child?
Which languages is most often spoken by adults in the home?
In which language do you wish to receive written communications from the school?*

EnglishSpanish
Residence – where is your child/family currently living? ((Information is use for CALPADS and other school reports): Please check appropriate box:

In a single family permanent residence (house, apartment, condo, mobile home) (200)In a motel/hotel (110)In a shelter or transitional housing program (100)Unsheltered (car/campsite) (130)Other
Parent/Guardianship Information (with whom the student lives) – check all that apply

FatherMotherBothStep-FatherStep-MotherGuardianFoster/Group HomeOther
Is the above (checked) person (s) the student’s LEGAL guardian?

YesNo
Please complete a “Caregiver Affidavit”
If there is a legal custody agreement regarding this student, please check one

Joint CustodySole CustodyGuardian
DUPLICATE MAILING – If divorced/separated & joint custody allows duplicate mailing/information to be given to other parent, Please include their name, address, and phone number
Full Name*

First NameLast Name
Phone Number
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MOST RECENT SCHOOL ATTENDED
School Name
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Grade(s)
Date
Are there psychological or confidential reports available from your child’s former school?

YesNo
What special services has your child received? (please check all boxes that apply)
Special Education

Resource (RSP)Special Day Class (SDC)Speech/Language504
Other

Gifted (GATE)Remedial MathRemedial ReadingCounselingEnglish Language DevelopmentHelp to Improve Attendance/ BehaviorOther
Student 4 Information
Student 4 Name*

First NameMiddle NameLast Name
Gender*

MaleFemale
Student’s Date of Birth*

MonthDayYear
Date
Grade-Level for 2020-2021 school year*
WHAT IS YOUR CHILD’S ETHNICITY? ( (Information is used for CALPADS and other school reports)*

Hispanic or Latino (A person of Cuban,Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race)Not Hispanic or Latino
WHAT IS YOUR CHILD’S RACE? (Information is used for CALPADS and other school reports) The above part of the question is about ethnicity, not race. No matter what you selected above, please continue to answer thefollowing by marking one or more boxes to indicate what you consider your race to be.

American Indian or Alaskan Native(100)(Personas cuyo origen es de los pueblos nativos de Norte, Centro o Sudamérica)Chinese (201)Japanese (202)Korean (203)Vietnamese (204)Asian Indian (205)Laotian (206)Cambodian (207)Hmong (208)Other Asian (299)Hawaiian (301)Guamanian (302)Samoan (303)Tahitian (304Other Pacific Islander (399)Filipino/Filipino American (400)African American or Black (600)White (700)
Date first attended school in the U.S.

MonthDayYear
Date
Date first attended school in California

MonthDayYear
Date
Birth Place

CityStateCountry
Home Language Survey (Indicate only one language (most frequently used) per line)
Which language did your child learn when he/she first began to talk?
Which language does your child most frequently speak at home?
Which language do you (the parent or guardians) most frequently use when speaking with your child?
Which languages is most often spoken by adults in the home?
In which language do you wish to receive written communications from the school?*

EnglishSpanish
Residence – where is your child/family currently living? ((Information is use for CALPADS and other school reports): Please check appropriate box:

In a single family permanent residence (house, apartment, condo, mobile home) (200)In a motel/hotel (110)In a shelter or transitional housing program (100)Unsheltered (car/campsite) (130)Other
Parent/Guardianship Information (with whom the student lives) – check all that apply

FatherMotherBothStep-FatherStep-MotherGuardianFoster/Group HomeOther
Is the above (checked) person (s) the student’s LEGAL guardian?

YesNo
Please complete a “Caregiver Affidavit”
If there is a legal custody agreement regarding this student, please check one

Joint CustodySole CustodyGuardian
DUPLICATE MAILING – If divorced/separated & joint custody allows duplicate mailing/information to be given to other parent, Please include their name, address, and phone number
Full Name*

First NameLast Name
Phone Number
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MOST RECENT SCHOOL ATTENDED
School Name
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Grade(s)
Date
Are there psychological or confidential reports available from your child’s former school?

YesNo
What special services has your child received? (please check all boxes that apply)
Special Education

Resource (RSP)Special Day Class (SDC)Speech/Language504
Other

Gifted (GATE)Remedial MathRemedial ReadingCounselingEnglish Language DevelopmentHelp to Improve Attendance/ BehaviorOther
Parent/Guardian
Parent/Guardian 1 Information
Parent/Guardian 1 Name*

First NameLast Name
E-mail*
example@example.com
Home Phone
Cell Phone
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is Resident Address same as Mailing Address?

YesNo
Resident Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Education – Check the response that describes the education level of the most educated parent. (Information is use for CALPADS and other school reports):

Graduate Degree or Higher (10)College Graduate (11)Some College or Associate’s Degree (12)High School Graduate (13)Not a High School Graduate (14)
Parent/Guardian 2
Parent/Guardian 2 Name

First NameLast Name
E-mail
example@example.com
Home Phone
Cell Phone
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is Resident Address same as Mailing Address?

YesNo
Resident Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Education – Check the response that describes the education level of the most educated parent. (Information is use for CALPADS and other school reports):

Graduate Degree or Higher (10)College Graduate (11)Some College or Associate’s Degree (12)High School Graduate (13)Not a High School Graduate (14)
Submitter's Signature*

Clear
Submitter's E-mail*
example@example.com
Should be Empty:

2021-2022 Student Enrollment Form

Student Information

Please complete a “Caregiver Affidavit”

MOST RECENT SCHOOL ATTENDED

What special services has your child received? (please check all boxes that apply)

Please complete a “Caregiver Affidavit”

MOST RECENT SCHOOL ATTENDED

What special services has your child received? (please check all boxes that apply)

Please complete a “Caregiver Affidavit”

MOST RECENT SCHOOL ATTENDED

What special services has your child received? (please check all boxes that apply)

Please complete a “Caregiver Affidavit”

MOST RECENT SCHOOL ATTENDED

What special services has your child received? (please check all boxes that apply)

Parent/Guardian